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					KATHY NAPOLI COUNSELING, LLC
427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
 kathyanapoli@yahoo.com | www.kathycounseling.com




Welcome to Kathy Napoli Counseling, LLC!
I am honored to have the opportunity to work with you or your child. This packet contains
information and forms that I will need to have on file for the first meeting.

Please review and complete the following documents:


     1. Disclosure Statement — to be reviewed and signed.
     2. Adult Client Information Form — to be completed and returned – if applicable
     3. Minor Consent Form – if applicable
     4. Parental Confidentiality Agreement – if applicable
     5. Parent Intake Form – to be completed and returned – if applicable
     6. Colorado Notice Form of HIPAA Legislation — to be reviewed and signed.




Please retain a copy of this information for your records.


Thanks!

Kathy Napoli




Kathy Napoli Counseling, LLC
7/11
KATHY NAPOLI COUNSELING, LLC
427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
 kathyanapoli@yahoo.com | www.kathycounseling.com



                                                   Disclosure Statement

Kathy Napoli Counseling is committed to the patient’s rights of information regarding office policy, non-discrimination,
confidentiality, consent and competent service. In keeping with this policy, I have listed below various office policies for your
information. Please read through these, ask any questions you may have and sign on the other side.

You may call 970.275.9596 regarding any questions you may have (i.e. billing, appointments, etc.). After hours, leave a voice mail
message with your contact information and you will be contacted the next business day. Kathy Napoli Counseling is not a 24 hour
counseling center. In an emergency, please call 911.

FULL NAME AND CREDENTIALS: Kathleen Ann Napoli, MSW, LCSW (Licensed Clinical Social Worker: Colorado License #
266).

The practice of both licensed and unlicensed persons in the field of psychotherapy is regulated by the Colorado State Departments
of Regulatory Agencies. Although the exact length of treatment is difficult to predict, Kathy will be glad to discuss her average
treatment duration for conditions similar to yours. Kathy will also be willing to discuss what other treatment options might be
available and the possible effectiveness of those alternatives. You may, at any time, seek a second opinion from another therapist
and/or may terminate therapy at any time without penalty.

Consistent with the established moral and ethical position of Kathy Napoli Counseling, LLC, recent Colorado law requires that any
individual seeking any counseling services must be informed that sexual contact between patient and therapist is not a part of any
recognized therapy. Sexual intimacy between patient and therapist is never appropriate, is illegal, and should be reported in
writing to the Department of Regulatory Agencies, Mental Health Section, 1560 Broadway, Suite 1340, Denver, Colorado 80202,
or by phone at 303-894-7766. If you have any concerns or complaints about licensed or unlicensed mental health practitioners,
you can contact the State Grievance Board.

SESSIONS
Sessions are typically scheduled for 50-55 minutes at a frequency to be determined by Kathy and the client. You may be referred
to a health care provider or support group in the community, or a combination of the two if necessary. It is essential for you to feel
comfortable with your counselor.

PAYMENT POLICY
Kathy Napoli sees clients on a fee-for-service basis only. The client/parent is responsible for payment in full at the time of each
session. Kathy Napoli charges $70.00 per fifty to fifty-five (50-55) minute sessions. My policy is for each person receiving
counseling or testing services to pay for such service at the time the professional services are rendered. Any other arrangements
must be made in advance. A $25 administrative fee will be charged on all checks that are returned for non-sufficient funds.

Initials ____ / _____


Phone consultations are billed in 15-minute increments ($25.00 minimum). All calls over five minutes will be billed accordingly.
In case of an emergency, please call 911. Any additional work by a counselor, such as providing summary notes to a third party,
will be billed at a prorated rate based on our current individual session rate ($70.00 or $1.16 per minute).

Please note: Charges for testing services and educational resources are in addition to the regular per-session fee.

INSURANCE
Many insurance plans reimburse for some portion of psychotherapy. Please direct questions about reimbursement amounts and
timeliness to your insurance company. Kathy Napoli is not contracted (in network, preferred provider) with any insurer. I will
provide you with a receipt for the counseling service at your appointment that may be used to submit for reimbursements if you
choose. Please note that I do not complete any insurance paperwork.


Kathy Napoli Counseling, LLC
7/11
KATHY NAPOLI COUNSELING, LLC
427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
 kathyanapoli@yahoo.com | www.kathycounseling.com



CANCELLATIONS
I understand that it may, at times, be necessary to cancel an appointment. To help be most efficient and responsible in the use of
my time, I require that any changes or cancellations be made at least 24 hours in advance. Any changed, cancelled, or missed
appointment with less than 24-hour notice will be charged $70.00.


CONFIDENTIALITY
The confidentiality of the counseling provided by me is protected by law. Unless you grant me permission to do so in writing, I
will neither inform anyone that you are receiving therapy, nor disclose the content of any session. The only circumstances under
which such professional confidentiality may be broken is if one or more of the following conditions apply:

         If you pose a serious physical danger to yourself or to another person.
         If you disclose that you or another person has physically or sexually abused or molested a child, an incompetent or
         disabled person.
         If you disclose that a child, an incompetent or a disabled person is suffering because of neglect.

If abuse or neglect is disclosed under the conditions given above, I am mandated by Colorado law to report such information to an
appropriate state agency.

If you elect to use your health insurance plan to assist in the payment of treatment then you understand that your insurance carrier
and the National Information Center will have access to pertinent data needed for claim processing.

FINANCIAL AGREEMENT AND AUTHORIZATION FOR TREATMENT
I have been informed of and read the preceding information and agree to it. I authorize treatment of the person named below and
agree to pay all fees as stated above.



___________________________________                            ___________________________________
Signature of Client or Legal Guardian                          Signature of Spouse (when in joint therapy)


___________________________________                            ___________________________________
Date                                                           Date


___________________________________                            ___________________________________
Signature of Counselor                                         Date




Kathy Napoli Counseling, LLC
7/11
KATHY NAPOLI COUNSELING, LLC
427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
 kathyanapoli@yahoo.com | www.kathycounseling.com



                               Confidential Adult Client Information
Personal Information:                                          Today’s Date: ____________
Last Name: __________________________ First __________________ Middle Initial: ____
Address:__________________________________________________________________
City: _______________________________ State_____Zip _____________________
Occupation _________________________________
Highest Level of Education _________________
Home Phone: ________________ Work Phone: __________________
Cell Phone ___________________
But prefer you contact me at _____________or Email Address: ___________________
Birth Date: __________ Age: ______                Sex: Male ______ Female _______
Marital Status: Single ____ Married ____ Partnered ____ Divorced ____ Separated ____
Engaged ____
How long ___________ If married/partnered, spouse/partner’s name: ___________________
Is your spouse/partner supportive of you seeking counseling? _________________________
Do you have children? ________ Ages: _________________________________
In case of emergency please notify: ______________________________________
Medical History:
Are you currently under medical care? ____ If yes, please indicate reason:_______________
___________________________________________________________________________
Physician’s Name _____________________________ Phone: ____________________
Do you (or spouse if marriage counseling) take any prescription medications? _____ If yes,
what are they?
___________________________________________________________________________
Other significant medical history
___________________________________________________________________________
Current Functioning:
What are your strengths?
___________________________________________________________________________
___________________________________________________________________________
__________________________________________________________________________
What gives you the most pleasure in life?
___________________________________________________________________________
Kathy Napoli Counseling, LLC
7/11
KATHY NAPOLI COUNSELING, LLC
427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
 kathyanapoli@yahoo.com | www.kathycounseling.com



___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
What fears or concerns to do you have?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
What are your most important hopes and dreams?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Please describe your friendships, community activities, and spirituality (if any):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Counseling History:
Have you previously seen a counselor/therapist/psychologist/psychiatrist? _________
Name/Date/Location: ____________________________________________________
When was your last appointment with any of the above? ________________________
Have you ever attempted suicide? _____ Have any family members attempted suicide? ____
In your own words, write why you are seeking counseling:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
How long have these concerns been causing you distress? ___________________________
By whom were you referred to this counseling center? _______________________________
How do you hope counseling will help? ___________________________________________
__________________________________________________________________________
Is there anything else you feel that is important for the counselor to know (please use back):
Kathy Napoli Counseling, LLC
7/11
KATHY NAPOLI COUNSELING, LLC
427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
 kathyanapoli@yahoo.com | www.kathycounseling.com



                                  Consent for Counseling Services to Minors
In order for minor children/adolescents to receive counseling services, it is necessary for the parent or legal guardian to
grant permission for such services to occur.

Names and date of birth of child(ren) to receive counseling services:
Name _________________________________________________ Date of Birth ________________
Name _________________________________________________ Date of Birth ________________
Name _________________________________________________ Date of Birth ________________
Name of person requesting services __________________________________________________
Your relationship to child(ren): Parent       Stepparent         Guardian          Grandparent        Other
Are you legal parent or custodian to above-named children?       Yes      No
I hereby swear that I have legal right to obtain treatment for the above-named children:     Yes      No

In instances of divorce, it is essential that the legal custodian of the child(ren) grant permission for the services. If you are a
divorced parent, a stepparent, a grandparent, a guardian, or other, you may be asked to provide a copy of the court order which
names you the legal custodian of the above children.

Are you willing to do so?      Yes           No
            If the answer to any of the above questions is “No,” counseling services ca not be provided to the above-
            named child(ren) until a copy of the court order which names you the legal custodian is provided to this
            office.

I acknowledge that both natural parents, even though divorced, may have a right to obtain from the provider named below
information regarding the nature and course of treatment of the child(ren).

        Colorado State law mandates the reporting of certain types of child abuse, including physical abuse, sexual abuse,
         unlawful sexual intercourse, neglect, emotional and psychological abuse. All actual or suspected acts of child abuse will
         need to be reported to the appropriate agency.
        This treatment may also include referral to other appropriate State and County agencies for further counseling.




I, _________________________________, consent to Kathy Napoli in providing counseling services to the child(ren)
named above. These services may include ( ) Clinical services; ( ) Counseling/Psychotherapy; or Other services
_________________________________________




___________________________________________________                            ________________________
Signature of person authorizing consent                                                Date




Kathy Napoli Counseling, LLC
7/11
KATHY NAPOLI COUNSELING, LLC
427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
 kathyanapoli@yahoo.com | www.kathycounseling.com




                                     Parent Confidentiality Agreement


Dear Parent or Guardian,

A young person is more likely to disclose sensitive information to a counselor if he or she is provided with confidential
services and has time alone with the counselor to discuss his or her issues. The most practical reason for clinicians to
grant confidentiality to an adolescent client is to facilitate accurate and appropriate treatment.

Experienced clinicians recognize that candid and complete information can be gathered only by speaking with the
adolescent patient alone and by clarifying with whom the information will be shared. If an assurance of confidentiality
is not extended, this may create an obstacle to the safe environment of the counseling relationship.

I encourage teenagers to share information about their emotional and mental health with their parents or guardians.
However, there will be some things that your teenage son or daughter would rather talk about exclusively with a
counselor.

Work with an adolescent is generally more productive if parents voluntarily agree to not request information about the
adolescent’s private session. I ask your permission to keep what is discussed in our sessions confidential.
“Confidential” means I will only share information with you if your teenage son or daughter says it’s alright. The
counselor agrees to share with the parent(s) any information which is necessary for the safety of the adolescent.




I agree that the counselor will determine what information, in her professional judgment,
 is appropriate to be shared with the parent/guardian(s) concerning treatment issues, and what
information, in the discretion of the counselor, will remain confidential between my adolescent/child
and the counselor.

____________________________________                              _______________________
Parental/Guardian Agreement                                               Date

____________________________________                              _______________________
Witness                                                                   Date




Kathy Napoli Counseling, LLC
7/11
KATHY NAPOLI COUNSELING, LLC
427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
 kathyanapoli@yahoo.com | www.kathycounseling.com



                                             Parent Intake Form

    1. Identifying Information:

        Please list each family member’s name, age, relationships to child, and occupation:




        Provide names and information of other people living in the home:




    2. Cultural Background/Family History:

        Please share any ethnic customs, special observances that are important to your family:




        Please share family history or dynamics. Include any separations, divorces, deaths, moves, changes

         in child care, and other significant events in your child’s life:




        Please describe the relationship between your child and other members of your family:




Kathy Napoli Counseling, LLC
7/11
KATHY NAPOLI COUNSELING, LLC
427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
 kathyanapoli@yahoo.com | www.kathycounseling.com



    3. School History:

        Day care (if any):

        Preschool (if any):

        Early Childhood classes/experiences (if any):



        Names of schools and dates/grades attended:



        Grades repeated (if any):


        Interruptions in schooling (if any):


        Special Services provided at schools (Special Education, 504 plan, Health Care plan, etc. if any):




    4. Developmental History:

        Length of Pregnancy:

        Complications:

        Birth Complications (if any):

        Extended Hospitalization:

        Other significant events with pregnancy/birth:

        Developmental Milestones: Sitting:___________ Standing:_________ Walking:__________

         Speech:___________ Fine Motor:____________ Gross Motor:_____________

         Social/Interpersonal Skills:_____________________

        Other Developmental Issues/Concerns:_______________________________________




Kathy Napoli Counseling, LLC
7/11
KATHY NAPOLI COUNSELING, LLC
427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
 kathyanapoli@yahoo.com | www.kathycounseling.com



    5. Health History:

        Any major illnesses/injuries (please provide description and age of child):




        Any current medical diagnosis:



        Current Medications (if any):



    6. Current Functioning:

             Please describe your child’s strengths:




             What does your child do for fun:



             Please describe your child’s social skills (i.e. ability to make and keep friends, interact with other

              children):




             Please describe your child’s relationship with parents and siblings:



             Please tell me a little bit about your family and child’s interests, hobbies, activities, etc:




             Please describe your child’s daily routine (wake-up/bed time/homework time/etc.):




Kathy Napoli Counseling, LLC
7/11
KATHY NAPOLI COUNSELING, LLC
427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
 kathyanapoli@yahoo.com | www.kathycounseling.com



             Please describe type of discipline used at home:




             Please describe your child’s self-image (how you believe they perceives or feel about self):




             Please describe your child’s ability to follow directions (regarding homework, chores, etc):




             Please describe your child’s adaptability (handling changes):



             Please describe your child’s problem solving abilities:




             Please describe any concerns that you have about your child:



             Please describe your ideas of the cause of the concern:




             Please describe any previous interventions that have been implemented (tutoring, counseling,

              etc.):


             Please describe any significant family stresses/traumas that may have an impact on your child’s

              social/emotional functioning:



             Please provide any additional information that was not addressed above:



Kathy Napoli Counseling, LLC
7/11
 KATHY NAPOLI COUNSELING, LLC
 427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
  kathyanapoli@yahoo.com | www.kathycounseling.com



                      COLORADO NOTICE FORM OF HIPAA LEGISLATION

 Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information

 THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY
 BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
 REVIEW IT CAREFULLY.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
 Your counselor may use or disclose your protected health information (PHI), for treatment, payment, and
 health care operations purposes with your consent. To help clarify these terms, here are some definitions:

 ―PHI‖ refers to information in your health record that could identify you.
 ―Treatment, Payment, and Health Care Operations‖


          – Treatment is when your counselor provides, coordinates or manages your health care and other
          services related to your health care. An example of treatment would be when your counselor
          consults with another health care provider, such as your family physician or another psychotherapist.

          – Payment is when you obtain reimbursement for your healthcare. Examples are if your counselor
          discloses your PHI to your health insurer for reimbursement for health care.

          – Health Care Operations are activities that relate to the performance and operation of your
          counselor’s practice. Examples of health care operations are quality assessment and improvement
          activities, business related matters such as audits, administrative services, case management, and care
          coordination.

 ―Use‖ applies only to activities within your counselor’s [office, clinic, practice group, etc.] such as sharing,
    employing, applying, utilizing, examining, and analyzing information that identifies you.

 ―Disclosure‖ applies to activities outside of your counselor’s [office, clinic, practice group, etc.] such as
     releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization
 Your counselor may use or disclose PHI for purposes outside of treatment, payment, or health care
 operations when your appropriate authorization is obtained. An ―authorization‖ is written permission above
 and beyond the general consent that permits only specific disclosures. In those instances when your
 counselor is asked for information for purposes outside of treatment, payment or health care operations,
 your counselor will obtain an authorization from you before releasing this information. Your counselor will
 also need to obtain an authorization before releasing your Psychotherapy Notes. ―Psychotherapy Notes‖ are
 notes your counselor has made about your conversation during a private, group, joint, or family counseling
 session, which your counselor has kept separate from the rest of your medical record. These notes are
 given a greater degree of protection than PHI.


 Kathy Napoli Counseling, LLC
 7/11
KATHY NAPOLI COUNSELING, LLC
427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
 kathyanapoli@yahoo.com | www.kathycounseling.com



You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each
revocation is in writing. You may not revoke an authorization to the extent that (1) your counselor has relied

Initials ____ / _____

COLORADO NOTICE FORM OF HIPAA LEGISLATION

on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance
coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

Your counselor may use or disclose PHI without your consent or authorization in the following
circumstances:

Child Abuse – If your counselor has reasonable cause to know or suspect that a child has been subjected to
    abuse or neglect, your counselor must immediately report this to the appropriate authorities.

Adult and Domestic Abuse – If your counselor has reasonable cause to believe that an at-risk adult has
   been mistreated, self-neglected, or financially exploited and is at imminent risk of mistreatment, self-
   neglect, or financial exploitation, then your counselor must report this belief to the appropriate
   authorities.

Health Oversight Activities – If the Grievance Board for Unlicensed Psychotherapists or an authorized
   professional review committee is reviewing my services, your counselor may disclose PHI to that board
   or committee.

Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made
   for information about your diagnosis and treatment or the records thereof, such information is privileged
   under state law, and your counselor will not release information without your written authorization or a
   court order. The privileged does not apply when you are being evaluated or a third party or where the
   evaluation is court ordered. You will be informed in advance if this is the case.

Serious Threat to Health or Safety – If you communicate to your counselor a serious threat of imminent
   physical violence against a specific person or persons, your counselor has a duty to notify any person or
   persons specifically threatened, as well as a duty to notify an appropriate law enforcement agency or by
   taking other appropriate action. If your counselor believes that you are at imminent risk of inflicting
   serious harm on yourself, your counselor may disclose information necessary to protect you. In either
   case, your counselor may disclose information in order to initiate hospitalization.

Worker’s Compensation – your counselor may disclose PHI as authorized by and to the extent necessary to
  comply with laws relating to worker’s compensation or other similar programs, established by law, that
  provided benefits for work-related injuries or illness without regard to fault.

 IV. Patient’s Rights and Psychotherapist’s Duties




Kathy Napoli Counseling, LLC
7/11
KATHY NAPOLI COUNSELING, LLC
427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
 kathyanapoli@yahoo.com | www.kathycounseling.com



Patient’s Rights:

Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of
   protected health information regarding you. However, your counselor is not required to agree to a
   restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You
   have the right to request and receive confidential communications of PHI by alternative means and at
   alternative locations. (For example, you may not want a family member to know that you are seeing your
   counselor. On your request, your counselor will send your bills to another address.)

Initials ____ / _____

COLORADO NOTICE FORM OF HIPAA LEGISLATION


Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in your
   counselor’s mental health and billing records used to make decisions about you for as long as the PHI is
   maintained in the record. Your counselor may deny your access to PHI under certain circumstances, but
   in some cases you may have this decision reviewed. On your request, your counselor will discuss with
   you the details of the request and denial process.

Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained
   in the record. Your counselor may deny your request. On your request, your counselor will discuss with
   you the details of the amendment process.

Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On
   your request, your counselor will discuss with you the details of the accounting process.

Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even
   if you have agreed to receive the notice electronically.

Psychotherapist’s Duties:

Your counselor is required by law to maintain the privacy of PHI and to provide you with a notice of my legal
   duties and privacy practices with respect to PHI.

Your counselor reserves the right to change the privacy policies and practices described in this notice.
   Unless your counselor notifies you of such changes, however, your counselor is required to abide by the
   terms currently in effect.

If Kathy Napoli Counseling revises its policies and procedures, your counselor will notify you by mail.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision your counselor makes about access to
your records, or have other concerns about your privacy rights, you are encouraged to discuss this with
your counselor prior to your first session.

Kathy Napoli Counseling, LLC
7/11
KATHY NAPOLI COUNSELING, LLC
427 Belleview Suite 205A | PO BOX 4368| Crested Butte CO 81224 | PH: 970.275.9596|
 kathyanapoli@yahoo.com | www.kathycounseling.com



If you believe that your privacy rights have been violated you have the option to send a complaint. You can
either send the complaint directly to me or you may also send a written complaint to the Secretary of the
U.S. Department of Health and Human Services.

You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file
a complaint.

Initials ____ / _____

COLORADO NOTICE FORM OF HIPAA LEGISLATION


VI. Effective Date, Restrictions, and Changes to Privacy Policy

This notice will go into effect on January 26, 2009.

Kathy Napoli Counseling reserves the right to change the terms of this notice and to make the new notice
provisions effective for all PHI that your counselor maintains. Kathy Napoli Counseling will provide you with
a revised notice by mail within ten business days prior to changes.

VII. Client Signature

I have read the above terms and understand them as stated. I have been informed of my therapist’s policies
and practices to protect the privacy of my health information.



___________________________________                      ___________________________________
Signature of Client or Legal Guardian                    Signature of Spouse (when in joint therapy)


___________________________________                      ___________________________________
Date                                                     Date


___________________________________                      ___________________________________
Signature of Counselor                                   Date




Kathy Napoli Counseling, LLC
7/11

				
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