Please give us complete information, if you agree to having The Counseling Center at CELA leave voicemail messages, regarding how you would like voicemail messages to be left. For example, do you want us to say the agency's name in voicemails we may leave? Do you want us to use your name or a different name in voicemail messages? Do you want us to leave voicemail messages only in certain situations, e.g., only regarding appointments?

Are there only certain situations in which you would like us to email? For instance only email appointment reminders and use the telephone to provide all other messages? NOTE: email correspondence is not considered to be a confidential medium of communication.

Please do not hesitate to ask any questions you may have, to ask for clarification of any information, or to ask for more information. Check the options below to let us know how you prefer contacting and communicating with The Counseling Center at CELA.

The Counseling Center at CELA offers sessions by email, video, telephone, and in combinations.

The Counseling Center at CELA offers the following payment options: (1) individualized payment plans; (2) sliding fee scales; (3) reduced rates; (4) limited availability pro bono (no charge) sessions. Please contact us for more information and to set up an individualized payment option.

Write your name and the date and the time that you finished filling out this form in all of the spaces provided. Providing your name as well as the date and the time you completed the form acknowledges that you: (1) have read and understood each individual questions and the sections of this form, as well as all of The Counseling Center at CELA policies, and the information requested and/or provided; (2) have been given ample opportunity to ask any and all questions you may have; and (3) have provided information that is accurate and correct to the best of your knowledge.

I understand and agree that The Counseling Center at CELA and Roselle P. O'Brien, LMHC, are providing mental health and support services to myself. I have received, read, and understand The Counseling Center at CELA's Policy Statement, Privacy Notice, HIPAA Statement, and Client's Bill of Rights. I have been provided with opportunities to ask questions about these policies. I understand that therapy can be terminated by myself at any time. I understand that therapy can be terminated by The Counseling Center at CELA/Roselle P. O'Brien. LMHC as per The Counseling Center at CELA Policy Statement. By filling in the date and time, below, I am certifying that I have read, understand, and agree to the aforementioned and that I am the client agreeing to receiving services from The Counseling Center at CELA/Roselle P. O'Brien, LMHC.