Please give us complete information, if you agree to having CREARTH leave voicemail messages, regarding how you would like voicemail messages to be left. For instance, 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 information 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 option below to let us know how you prefer contacting and communicating with CREARTH.

CREARTH offers sessions by email, video, telephone, and in combinations.

Creative arts areas include but are not limited to: visual arts; music and sound; culinary arts; language arts (written, spoken, and sung word); mindfulness and meditation; spirituality; religious practices; movement and exercise; gardening and horticulture arts; crafts such as woodworking, textiles (including sewing, quilting, crochet, and knitting); photography.

Payment is due at time of service. CREARTH offers the following payment options: (1) paying the regular rate of $120.00 for a 60-minute session or $150.00 for a 90-minute session; (2) individualized payment plans. Individualized payment plan options include sliding fee scales, reduced rates, limited availability pro bono (no charge) sessions. Please contact CREARTH for more information and/or to arrange an individualized payment plan option.

Write your name and the date and the time that you finished filling out this form in all of the spaces provided below. Providing your name as well as the date and the time you completed the form acknowledges that: (1) you have read and understood each of the individual questions and the sections of this form, and the information requested and/or provided; (2) you have been given ample opportunity to ask and and all questions you may have; (3) you have provided information that is accurate and correct to the best of your knowledge; and (4) you are the person completing this form.

I understand and agree that Creative Arts Therapy & Integrative Care (CREARTH) and Roselle P. O'Brien, REAT, are providing Expressive/Creative Arts experiential sessions to myself. I have received, read, and understand CREARTH's Policies Statement and Guiding Principles, and the REAT Code of Ethics. I have been provided with opportunities to ask questions about these policies. I understand that Expressive/Creative Arts sessions can be terminated by myself at any time. I understand that Expressive/Creative Arts sessions can be terminated by CREARTH/Roselle P. O'Brien, REAT as per the CREARTH Policies Statement. By filling in the date, time, and signature below I am certifying that I have read, understand, and agree to all the aforementioned and that I am the client agreeing to receiving services from Creative Arts Therapy & Integrative Care (CREARTH)/Roselle P. O'Brien, REAT.