Genesis Counseling | Genesis Counseling Intake Information

Intake Information

The information contained in this form is strictly confidential, protected by law, and will not be released to any third party without written request and permission. Please read carefully. This form must be filled out in it's entirety before counseling services can be rendered.

* Required Fields
Title:	*	Mr. Mrs. Ms. Miss.
First Name:	*
Middle Name:
Last Name:	*
Marital Status:	*	Single Mar Div Sep Wid

Contact Information
Email:	*
Address:	*
Unit/Apt.:
City:	*
State:	*
Zip:	*
Phone Number:	*	- - ext.

Refered By:
Other family members seen here?		Yes No

Additional Information
a) Are you affiliated with a Church or Denomination?

b) Are you currently receiving services from a counselor or mental health provider?
Yes No
c) Are you currently using prescribed medications for any psychiatric or emotional conditions?
Yes No *If yes, please name medication(s):*

Duty to Warn
In accordance with California law, we are required to report to the appropriate authorities OR third parties the following: Any information leading to suspicion or knowledge of the physical or sexual abuse or neglect of a minor child. Any information leading to suspicion of knowledge of danger to a third party. Any information leading to suspicion or knowledge of suicide of a client seeking treatment from Genesis Counseling.

Payment Policy
Fees for services with Joe Dallas are $100.00 per 50-minute in-office session/$1,000 2-Day Intensive Individual Sessions /$1,200 2-Day Intensive Couples Sessions/$90 per phone counseling session/$50 per 4 email counseling sessions. Fees for three 50-minute phone counseling sessions with Dr. Mike Rosebush/$375 Payment is due BEFORE the beginning of each counseling session. PAYMENT BY CHECK APPLIES ONLY TO IN-OFFICE SESSIONS. ALL OTHER SERVICES MUST BE PAID BY CREDIT CARD. A fee of $100.00 will be charged for missed appointments without 48 hours prior notice. Payment missed for two consecutive sessions MAY result in termination of services. Genesis Counseling does NOT accept insurance payments.

Request for Services
* Type of counseling services requested:
In-Office ($100.00) Men's Two-Day Intensive ($1,000.00) Couples Two-Day Intensive ($1,200.00) Phone ($90.00) Email ($50.00)

Terms and Conditions

Please type I Agree* in the box below to continue.* Confirmation:


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