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Be the best that you can be
Informed Consent For Consultation
By signing this form I ________________
of sound mind; understand that I am participating in a consultation with a coach/counselor from Kami Wellness Center Inc. I also understand and agree to the limits of this consultation as outlined below:
- A onetime free consultation with Kami Wellness Center Inc. that will last up to 45 minutes;
- The purpose of the consultation is for me to have a chance to meet the counselor/coach before I start the counseling/coaching, to see if I feel comfortable, and to have any questions about this process answered;
- This consultation does not oblige me to enter into a helping relationship with Kami Wellness Center, and if I start working with Kami Wellness Center; this consultation was not considered a bio-psychosocial assessment or a therapy session;
- The information discussed is strictly confidential except; if I disclose any information that would indicate child abuse, elder abuse, intent to harm myself or harm anyone else; then the consultant at Kami Wellness Center Inc. reserves the right as a mandated reporter to call the authorities which would include 911 or the abuse hotline (1800-96-ABUSE);
If you are interested in a helping relationship with Kami Wellness Center Inc. to “be the best that you can be,” make an appointment today.
kamla@kamiwellnesscenter.com 3600 South State Rd 7, Suite 352, Miramar FL, 33023