TOUCH OF HEALING COUNSELING CENTER
                      Sandra Rawlings, MS, LPC, Director of Counseling
                               Andrew Provence, MS, LPC,
                       Donna McDowell, MA., Roger Gould, Intern

Welcome to the Touch of Healing Counseling Center with services provided by Sandra B. Rawlings, MS,
LPC, Andrew Provence, MS, LPC, Patrick Motley, MS, and Donna McDowell, MA., Roger Gould, intern,
PSI, Christian Counselors. In cooperation with the ministries of First Assembly of God in Griffin and Dr.
Randy Valimont, Senior Pastor has initiated this counseling ministry to provide to all parties who seek
professional assistance for individual, marriage, or family issues, regardless of their race, color, or religious
affiliation. It is the goal of this counseling ministry to assist those struggling with the cares of this life to
find wholeness, which can only be found in Christ Jesus, our Lord and Savior.

Christian Counseling is a joint venture of the counselor and the client, whereby healing and restoration are
sought through mutual insight exchange, behavioral change, and spiritual renewal. As such, your therapist
greatly depends upon you to adhere strictly to the following criterion in order that your investment reaps
optimal results.

All communications between the therapist and client is of a confidential nature and will not be breached,
unless required by law. Circumstances involving child abuse or safety concerns to self or to others will be
assessed in light of this limit. Discretion will be maintained when the need arises to release or obtain
information on behalf of the client. It is necessary to understand that communication regarding counseling
matters must be confined to the counseling session. Please do not discuss matters outside the counseling
     1. Only Current Licensed or Ph.D level therapist are to testify.
     2. To testify, the therapist must receive a subpoena.
     3. Signed authorization is a must if testifying for someone as a spouse or child.
     4. Client’s rights are waived by testifying in court, in that they are giving
          permission to reveal confidential information.

         During the course of the counseling session it may be necessary to request documentation
         information from your therapist for Attorneys, Human Resources Managers, Correction Officers,
         Courts, etc. Our practice guidelines are to provide a notarized affidavit for a cost of $75.00 to the
         client. Affidavits are legal documents used in court in the therapist’s sted. In the event the
         therapist is subpoenaed to court, the client agrees to pay $125.00 per hour for each hour the
         therapist is out of the office, with a minimum of two hours to be paid prior to Court. Payment
         is the responsibility of the client, as insurance companies do not cover court costs or loss of
         income for the therapist. The balance is due within 7 days after the hearing. Fees will be
         charged to your credit card on file unless other arrangements have been made.

Please contact the counseling office to schedule a counseling session. Unless prior arrangements have been
made all copays and fees are due at time of service. If it becomes necessary to cancel, please notify the
office 24 hours prior to your scheduled appointment time. Due to the number of individuals seeking this
service, it is important to try and keep all scheduled appointments. Should failure to attend by no/little
advance notice become an issue, you will be subject to a fee of $25.00. In the event that 2 of these fees are
debited to your account within 2 months, you must pay those fees prior to your next scheduled session.

Payment from cash clients is due at the time of service.

We accept cash, check, Visa, Master Card and/or Debit Card.

A $30.00 fee is charged for all checks returned from the bank for any reason.

A billing statement or receipt is generated only upon request.

In order to maintain standing appointments, your account must be kept current.

Clients who are Minors:
The adult accompanying a minor of the parent/guardian (s) is responsible for full payment.
Minors unaccompanied by an adult will be denied services (except in an emergency) unless payment has
been prearranged.

In addition to the above, I hereby waive the statute of limitations on collection and/or recovery in the state
of Georgia.
Thank you!

Insurance Information:
 Name of Company _______________________________________________

 Address: _______________________________________________________

 City: _______________________________ State: _____________________

 Policy Number: __________________________________________________

All phone contact should be directed primarily to (678) 688 3133. In cases of crisis where the therapist has
not made other arrangements, notify 911 or the local emergency room.

               Thank you for utilizing the Touch of Healing Counseling Center.
                   We want you to be all that God has created you to be!


Signature of Client or Responsible Party                                 Date

______________________________________________________                   ____________________________________
Witness                                                                  Date

                         2000 WEST MCINTOSH ROAD
                              GRIFFIN, GA. 30223
                                 678 688 3133

                          STATEMENT OF CLIENT RIGHTS
    1.   You have the right to be treated in a consistently competent, ethical, and respectful manner.

    2.   You have the right to stop receiving therapy without any obligation other than to pay for the
         services you have already received.

    3.   You have the right to ask questions about the approach and methods utilized, and to decline the
         use of certain therapeutic techniques.

    4.   You have the right to review your individual clinical records at any time.

    5.   You have the right of confidentiality. This means that, within the limits described below, we will
         not release identifying information about you to any person or agency without your permission.

    6.   In certain situations, we are required by law to reveal information about you to other persons or
         agencies WITHOUT YOUR PERMISSION.

             a.   If you threaten grave bodily harm or death to another person, we are required to inform
                  the intended victim and/or appropriate law enforcement agencies.

             b.   We are required to release to a court of law any information specifically described by a
                  court order.

             c.   We are required to report to the Department of Family and Children’s Services any
                  reasonable suspicion we have that a minor is being abused or neglected by you.

             d.   If a court of law has ordered you to have treatment or testing, the results of that treatment
                  or testing must be revealed to the court requesting the information.

I have read the above statements and acknowledge by my signature below that I fully understand them and
have no further questions.

___________________________________________                                        _____________________
Signature of Client or Guardian                                                    Date

____________________________________________                                       _____________________
Witness                                                                            Date

                  Touch of Healing Counseling Center
The following form, which will become a part of your confidential record, will enable us to gain a
quicker understanding of you. Please answer each question as completely and carefully as you
can. You may use the back of any page for additional information.

Section I – Patient Information


        Address                                                             City

        Zip                       email Address

        Phone                         Cell Phone                Pager #
        OK to leave detailed message:  home phone  work phone  cell phone

        Written Communication – OK to mail to:       home        work    email

        Date of Birth                              Social Security Number

        Marital Status                             Gender M / F Referred by

        Religious Affiliation                      Church                           Active / Inactive

        Employer                                                    Work Phone

Family member to notify in case of emergency:

Name                                                                        Relationship

Address                                                                     Phone

Section II – Insured Information

Client Relationship to Insured:  Self     Spouse      Child     other

If insured is other than “Self” please complete the following.

        Insured’s Name

        Address                                                             City

        State                     Zip              Phone                            Gender M/ F

        Date of Birth                     Marital Status            Social Security #

        Employer                                                    Work Phone

Section III – Family Members

                                                               Last Grade
Relationship       Name                              Age       Completed            Occupation




  Brother (s)

  Sister (s)


Describe any physical problems you have that require medication or physical care:

Are you currently receiving medical treatment or taking prescription medications?     yes    no

If yes, please list:

Have you had previous counseling?      yes    no    If yes, when?

Where and with whom?
                          Name                             Address

In your own words, briefly describe the main problem which prompted you to seek counseling at
this time:

Have there been times when the problem got better or disappeared?         yes    no

What do you think helped?

Were there times when the problem was especially bad?         yes     no

What made it so bad?

Are there other people who play a major role in causing your problem or are helping you to cope
with your problem?  yes  no

Explain briefly:

Section IV – Problem Area

In the following list, place a check mark next to each item which identifies an area of concern to
you. Place two check by those items which are most important. (You may add comments after
areas checked.)

            Anger                                                  Religious/Spiritual Concerns

            Depression                                             Sexual Concerns

            Education                                              Thoughts of suicide

            Eating difficulties                                    Trouble making decisions

            Fearfulness                                            Unhappy most of the time

            Financial problems                                     Use of alcohol

            Marital problems                              ______Use of alcohol by family member

            Physical problems                                      Use of drugs

            Problems with social relationships            _____Use of drugs by a family member

            Problems with children                                 Work

            Problems with parents                                  Worry

            Other – Please explain:

I hereby consent for Touch of Healing Counseling Center to treat the undersigned person. I
authorize Sandra B. Rawlings, MS, LPC and/or her designated staff to render to the patient
customary care, tests, and procedures ordered by Sandra B. Rawlings, MS, LPC. No identifying
information will be released without written consent, except in the case of emergency or as
required by law. Information regarding my involvement in outpatient counseling will be kept
confidential by Touch of Healing Counseling Center. For clients age 17 or under, the signature of
his/her legal guardian or custodial parent is required.

Signature                                                 Date

Parent or Guardian                                        Date

Witness                                                   Date

Promise to Pay Account

For and in consideration of services rendered and to be rendered to the named client, I/We jointly
and severally promise to pay and Touch of Healing Counseling Center all charges for services
rendered to and for the client. I/We hereby authorize payment direct to Sandra B. Rawlings, MS,
LPC and Touch of Healing Counseling Center of any benefits for charges incurred in connection
with the treatment of the client, otherwise made payable to me/us. I/We are financially
responsible to Touch of Healing Counseling Center for all charges regardless of insurance.

Client/Parent/Guardian                                  Date

Witness                                                 Date

Debit/Credit Card on File: (Please check the appropriate card) (Required)

MasterCard _____ Visa_____ Expiration Date:_______/_______/_______

Card Number__________________________________________________

Name as it appears on Card: _____________________________________

Signature: ____________________________________________Date:_______/_______/_______

Authorization to Release Information to Insurance

I authorize Sandra B. Rawlings, MS, LPC and Touch of Healing Counseling Center to release any
and all information regarding diagnosis, treatment and prognosis with respect to any physical or
mental condition and/or treatment of me to my insurance company or its legal representative as
indicated on the admission form. Any such disclosure shall be limited to information that is
reasonably necessary for the discharge of the legal or contractual obligations of my insurance

I understand the information obtained by use of this authorization will be used by my insurance
company to determine eligibility for benefits under the existing policy. Any information obtained
will not be released by my insurance company to any other persons or organizations unless I so

I know that I may request to receive a copy of this authorization. I know that I may revoke this
authorization at any time. I agree this authorization shall be valid during the pendency of this

Release of Information: At times, information may be requested from our office. In order to
expedite your request, a signed Consent for Release of Information form must be on file prior to
the release of any information from our office.

Clients Utilizing Insurance
Clients who carry insurance should remember that professional services are rendered and
charged to the client and not to the insurance company.

Co-payments and fees are due and payable at the time of your visit.
Touch of Healing Counseling currently accepts assignment of most insurance benefits.
We will allow 45 days for remittance of insurance benefits.
If we do not receive payment from your insurance company within the time frame, you will be
held responsible for the balance due.
It will then become your responsibility to clear your account with us and then collect monies due
you from your insurance company.
We cannot accept responsibility for collecting your insurance claim or negotiating a dispute.

Client/Parent/Guardian                           Date

Witness                                          Date


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