Career Counseling Intake Form

First Name: *

Last Name: *

Home Phone: *

Cell Phone: *

Home Address: *

City, State, Zip: *

Email Address: *

Date of Birth: *

Age: *

Assigned (Legal) Gender

Gender Identity

Preferred Pronouns

Sexual Orientation

Marital Status

Racial Identity

Do you have kids?

Yes

If so, how many

What age(s)

Preferred method of contact : *

How did you hear about us ? *

Employment Information (Company Name) *

Position Name *

Date of Employment *

SOCIAL MEDIA POLICY

Friending

Please do not send any requests to my personal social media sites, including Facebook, Instagram and Twitter. However, exceptions will be made for Avedian Counseling Center and Linkedin ONLY. I don’t accept personal contact requests from clients, including former clients since it can compromise your confidentiality.

Should you have any questions regarding my social media policy, please ask me, and I will clarify.

CONFIDENTIALITY

The session content and all relevant materials to the client’s sessions will be strictly held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons.

Limitations of such client held privilege of confidentiality exist and are itemized below:

1) If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.

2)If a client threatens grave bodily harm or death to another person.

3)If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4)Suspicions as stated above in the case of an elderly person who may be subjected to these abuses. Suspected neglect of the parties named in items #3 and # 4.

5)If a court of law issues a legitimate subpoena for information stated on the subpoena.

6)If a client involves a therapist in a conspiracy to commit a crime or a conspiracy to avoid detection from prosecution.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name. If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you.

CLIENT CONSENT

I understand that cancellations and re-scheduled sessions will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE.

I grant permission for case consult with other professionals as long as standard care is exercised to protect my privacy and confidentiality.

I have been advised regarding the limits of above stated confidentiality and I agree that I will not authorize the execution of a subpoena for any purpose. I hereby authorize my therapist to resist subpoenas executed by any other person or persons in order to protect and insure my privacy and confidentiality.

I agree to enter into a course of career counseling with Destiny Johnson, M.S., at a rate of $150 per session payable at the beginning of every meeting: *

Signature Below: *

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