Calm Spirit Counseling Form

Please complete this form to help the counselor understand your situation.

What do you want to talk about with the counselor?

How do you feel about that?

What do you think the problems is?

What would you like to see change in your life?

Have you ever talked to a counselor in the past? If so, please explain.

Are you taking any medication prescribed by a psychiatrist or physician to help you with your moods or emotions? If yes, please explain.

Please enter your name here:

Please enter your email address here so I can respond to you

By completing this information, you agree to the following:

• That you understand that online counseling is not psychotherapy, but support and guidance
• That you are not currently in crisis
• That you will pursue therapy with a mental health practitioner if you have thoughts of harming yourself or anyone else
• That you understand confidentiality. Interactions between client and counselor are confidential. The counselor will not discuss any part of counseling or consultation without your permission. The exceptions that the law requires to report are:
  • Incidents of child or elder abuse
  • Intent to commit suicide
  • Threats to to harm to yourself or another person

By using the submit button, I agree that I understand and accept all the above conditions.