Intake Forms & Informed Consent

MyCounselor is a provider of “Mental Health Services”. As such we must collect some information about you and your presenting concerns for our records (Intake Forms). We also need to provide you with some information about the services you will receive (Informed Consent). You’ll need to complete each of the following documents before your first session. Completing the documents prior to your first session is very important, as we can not provide you with services without these documents complete.

If you have any questions please give us a call at 855-593-4357 and we will be happy to answer them.

Each adult participating in sessions must complete the following:

Adult Intake Form

Clients age 18 and older must complete this form prior to the first scheduled appointment with one of our counselors.

Informed Consent Documents

This form contains a Counseling Service Agreement along with important information on Christian counseling, privacy, insurance and financial responsibilities.

If you are a parent or guardian scheduling family sessions, complete the Family Intake Form:

Family Intake Form

Clients receiving family counseling must complete this form prior to the first scheduled appointment with one of our counselors.

Payment Plan & Scholarship Forms

Payment Plan Request Form

Qualifying clients must complete this form prior to beginning weekly payments for services provided by our counselors.

Scholarship Request Form

Clients who qualify for the Strong Families Scholarship must complete this form prior to receiving financial assistance for counseling services.

Additional Forms

Authorization to Use & Release Personal Health Information (PH) Form

MyCounselor (MCO) may use or disclose your protected health information (PHI) for treatment, payment, and health care operations for the purposes within your written authorization.

Sexual Identity Therapy Advanced Information Consent

Clients receiving sexual identity therapy must complete this form prior to the first scheduled appointment with one of our counselors.

Court Service Request Form

Clients needing MyCounselor to provide reports and documentation to assist with legal matters must complete a Court Service Request form.

Church Liability Release Form | Columbia

Clients of MyCounselor’s Columbia office must release Columbia Church of Christ from liability in connection with services provided.

Church Liability Release Form | Kansas City

Clients of MyCounselor’s Kansas City office must release Emmaus Church from liability in connection with services provided.

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