Name
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First Name
Last Name
Email Address
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
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Occupation
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Marital Status
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Gender
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Date of Birth
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Contact Preferences
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Why are you seeking help at this time?
Current problems/medication
Describe the problem(s) you are having at this time (Examples: family, friends, work, marriage, significant other, parenting, spiritual, health).
Medications:
Past Counseling
Describe your past experiences with counseling, if any. (Examples: support groups, spiritual support, diagnosis, treatment, medications, hospitalizations, etc.)
Specific Questions
Do you have any specific questions, concerns or needs that you think it is important for me to know?
Your Goals
If known, please list the goals you would like to achieve.
Additional Comments
Payment
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1. Payment to Dr. Mary Del Vecchio (DRMDV) must be made via check or PayPal. NOTE – If you cancel without 24 hour notice and a firm date to reschedule within 30 days, any fee paid is kept by DRMDV as a processing charge and lost revenue cost. YOU AGREE THAT DRMDV IS NOT RESPONSIBLE FOR LOSS I MAY INCURR FROM ANY MISTAKE OR NEGLECT IN DELIVERY OF THESE SERVICES THAT MAY CAUSE ME LOSS. FURTHERMORE IF MY ACTIONS WHEN WORKING WITH DRMDV RESULT IN DRMDV REALIZING LOSS OR CLAIM AGINST DRMDV I AGREE TO INDEMNIFY DRMDV AND MARY DEL VECCHIO PERSONALLY FOR ANY SUCH LOSS.
Scope of Services
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2. Understand this is NOT a crisis line but a fee for service agreement only, DRMDV does not provide diagnostic services nor file process insurance payment methods, therefore HIPPA is not required, nor this part of your permanent medical record. SCOPE OF SERVICES. I AM HIRING DRMDV FOR PASTORAL COUNSELING SERVICES. THESE SERVICES ARE BASED ON SPIRITUAL PRINCIPLES OF GUIDANCE THROUGH GOD’S GRACE AND WORKING WITH THE WHOLE PERSON. THE SERVICES ARE NOT PSYCHOTHERAPY, NOR LICENSED PSYCHOLOGICAL THERAPY. DRMDV DOES NOT PROMISE RAPID, COMPLETE OR PERMANENT IMPROVEMENT TO ANYONE RECEIVING PASTORAL COUNSELING SERVICES. I FUTHER HOLD DRMDV HARMLESS AND RELEASE HER FROM ANY CLAIM OF LOSS I MAY ASSERT AS RELATED TO MY HIRING DRMDV FOR PASTORAL COUNSELING SERVICES.
Electronic Communication
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3. DRMDV takes all precautions to protect your privacy when using the services: with a secure server, encryption protocols, and a secure firewall. DRMDV attempts best efforts to stop or limit any unauthorized access. Client records are maintained in accordance with professional guidelines, securely stored and kept confidential. Your information is not used in any other manner, and is not shared with any third parties or company. Keep in mind you are expected and agree maintain your own privacy as follows: If email/text or chat line is used you retain the right to request that sessions be deleted at any time and all service contacts be destroyed. Remember that direct chat sessions are not secure as they pass through public domains. Remember that the computer you use such as in school, workplace, library etc. is accessible to others. Your employer has the right to access your accounts and files and to review any contents. Avoid placing yourself in any situation where you do not want personal information viewed by others. Be sure to delete and empty your trash/recycle bins and erase any files generated when necessary. NOTE: The expectations to privacy protection DO NOT extend to issues of child abuse and endangerment, homicidal or suicidal behaviors and threats, and in rare cases even client records may be subpoenaed by court of law. State or Federal laws govern this. If you have additional privacy concerns contact DRMDV as matters may unfold where she is under court order or law enforcement direction to disclose portions of her records.
18 Years old
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I am 18 years old or older.
Governing Law
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THESE TERMS SHALL BE GOVERNED BY INTERPRETED ACCORDING TO THE LAWS OF THE STATE OF MINNESOTA. ANY DISPUTE ARISING OUT OF HIRING DRMDV SHALL BE SETTLED AS FOLLOWS: INFORMAL NEGOTIATIONS OR, SHOULD NEGOTIATIONS FAIL, THROUGH THE BINDING ARBITRATION WITH THE AMERICAN ARBITRATION ASSOCIATION’S (AAA) MINNEAPOLIS REGIONAL OFFICE AT 200 SOUTH SIXTH STREET, SUITE 700 MINNEAPOLIS, MN 55402 OR ALTERNATE AAA LOCATION. NOTE: BINDING ARBITRATION IS A PRIVATE (NO COURT/JURY) DISPUTE RESOLUTION PROCESS THAT IS FEE BASED AND CARRIES A LIMITED RIGHT OF APPEAL. BOTH SHALL PAY ALL OF THEIR OWN COSTS NECESSARY TO PROCEED IN ARBITRATION AND SHALL SPLIT AAA’S FEES EQUALLY. IF YOU FILE A LAWSUIT IN THE COURT SYSTEM YOU AGREE THAT BOTH SUBJECT MATTER AND PERSONAL JURISDICTION FOR ANY MATTER SHALL REST IN THE COUNTY OF WASHINGTON, STATE OF MINNESOTA.
BY CLICKING "ACCEPT" I AGREE TO BE BOUND BY THE TERMS ABOVE.
