IN HIS NAME OUTREACH, Inc.

3871 Harlem Rd, Cheektowaga, NY 14215

1887 Como Park Blvd., Lancaster, NY 14086

Phone: 716-464-3681

www.inhisnameoutreach.com

ONLINE CONSENT TO SERVICES

1. I hereby voluntarily consent to receiving counseling services from In His Name Outreach representatives or adjunct services recommended for my well being.

2. I am aware that the practice of counseling is not an exact science and I acknowledge that no guarantees have been made to me regarding the results of my expectations, that it is support services guided by the Word of God! I am aware that I may refuse any counseling or care services offered to me and terminate my care at any time.

Signature of Client/Responsible Party______Date______

3. I hereby authorize In His Name Outreach to retain, preserve, and use for research or teaching purposes information provided in the sessions without disclosure of my name or any other personal identification.

4. I understand that referrals may be made to other professionals (such as psychiatrists,

psychologists, etc.) by my counselor or service provider. In His Name Outreach, Inc. (which includes the referring counselor or service provider) is not responsible for payment to other professionals on my behalf or for the client receiving our care.

5. I understand that Skype appointments are as valid as an ‘In office service’ and are charged accordingly. I am responsible to supply payment for this service.

ONLINE COUNSELING POLICY- EMERGENCIES

Online Counseling does not provide "emergency services". If a client has an urgent concern, call the office and we will try to schedule an appointment with your counselor or service provider as soon as possible. Please contact your local Crisis Intervention Center for emergencies or call 911.

Witness: ______Signature: ______

Date:______Print Name: ______

*If signed by Responsible Person, complete one of the following:

a.) Client is unable to consent because he/she is a minor, ______years of age.

b.) Client is unable to consent because ______