Prior to receiving services, please read the following documentation regarding HIPAA Notice of Privacy Practices and Client Consent Information and then complete the form below.

* I understand that the service provided through Free To Be Me Healing Services is not intended for crisis situations and urgent needs. In a crisis situation, I agree to call 911 or local emergency services, or visit the nearest emergency room.  Information shared with my counselor is confidential except in the following circumstances: If I present as a danger to myself or others, mandated reporting of abuse of children or elders, or if I sign a release of information.

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Name *
Date *