Chosen for Victory Intake Form

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Please let us know your spiritual beliefs
Reason for seeking counselling now (check all that apply)

PLEASE READ BEFORE SIGNING!

Informed Consent

By law and professional ethics, your sessions are strictly confidential except under the following circumstances:

    • If Robert or Roxanne Frost is ordered by the court to testify or release records about you, he/she is obligated to do so.
    • If you are the perpetrator of child abuse (includes viewing child pornography), Robert and/or Roxanne are required by law to report.
    • If you are the perpetrator of elder or dependent adult abuse, Robert and/or Roxanne are required by law to report.
    • If you threaten to harm yourself, someone else or the property of others, Robert and/or Roxanne are required to report.

You are entering into a counselling relationship that has the potential to transform your life. Your problems will be identified and professionally treated. This is not a place for “quick fixes.” Change takes time, commitment and hard work. Clients who are serious about change will commit to several months of therapy based on their individual needs. Counselling is not always easy. You will be supported and understood but expect to be challenged as well. Regarding spirituality, Robert and Roxanne view people from a Christian perspective. They believe that everything and everyone is created by God. On the basis of this belief, Robert and Roxanne think all people should be treated with dignity, respect and value regardless of their belief system or lifestyle choices. They will not force their values upon you. However, their values may appear in their counselling styles.

Counselling Fees are $110.00 including GST for individual sessions, $150 including GST when both Robert and Roxanne are in session.

    • Payment is made the day of your session by credit card. You will be asked to provide your credit card number and expiry date at the beginning of your first session. The security code may also be needed.
    • 24 hours’ notice is required if you wish to cancel or reschedule your appointment (no exceptions).
    • You are responsible for payment of the full fee for late cancellations, late reschedules and missed sessions. Your credit card will be charged in any of these instances.

I have read and understand the above statements and agree to the session fee payment and the late cancellation/late reschedule/missed session policy:

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