Dr. Elaine Stevens Relationship Coaching & Consulting (New Client Form)

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* 1. Contact Information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Occupation

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* 3. Age

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* 4. Marital Status

Single

Married

Separated

Divorced

Widow/er

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* 5. Spouse's Name (if applicable)

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* 6. How did you hear about Dr. Elaine?

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* 7. What is your main reason for acquiring Dr. Elaine's consultation services?

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* 8. Confidentiality Statement
I understand that all sessions with Dr. Elaine Stevens are held in the strictest of confidence. Dr. Elaine Stevens will not reveal any information discussed during any of the sessions with anyone. The only exception to this rule is if Dr. Stevens foresees any life threatening situations OR if your records are subpoenaed by law. Should you choose to discuss any part of the session with someone else, that is your right, for it is your information to share as you wish.

Agree

Disagree

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* 9. Consent for Consulting Services and Financial Responsibility
I hereby give Dr. Elaine Stevens permission to consult with me concerning my relationship issues. I understand that Dr. Elaine Stevens will not be responsible for any adverse behavior or choices made by myself as a result of consultation services. I agree to pay all charges in full at the time of service, unless prior arrangements have been made. I also understand that if I need to cancel an appointment, I must do so at least 24 hours before the date of the appointment to avoid any charges.

Agree

Disagree

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* 10. Signature