Client Acknowledgement of Receipt of Information

I have read, understood and agree to the Pathways Christian Counseling Office Policies, Informed Consent and Service Agreements. I agree to pay Pathways Christian Counseling the designated fees for services provided to me as described in their Office Polices. I understand that I am personally responsible for all payments. I authorize the provider to furnish information to my insurance carrier concerning my treatment, as well as to receive payment of medical benefits. If insurance is not being used, I am responsible to pay the amount agreed upon with my provider.

I have received copies of Pathways Christian Counseling Client’s Rights and Responsibilities and Privacy Policies.

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Please print client name Date

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Signature of client

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Signature of spouse Date

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Signature of parent or guardian (if minor) Date