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INTAKE FORM

For Marriage Counseling, Please submit individual forms

Personal Data
Family Information
Religious Background
Medical Information
Counseling History
do hereby acknowledge and agree that I have requested ReNu-Hope Counseling, to provide counseling services to me in connection with psychological, emotional, relational, and spiritual aspects of life. I understand and agree that ReNu-Hope Counseling will only be providing spiritual guidance and support and will not be providing Clinical Psychotherapy.
do hereby acknowledge and agree that I have requested ReNu-Hope Counseling, to provide counseling services to me in connection with psychological, emotional, relational, and spiritual aspects of life. I understand and agree that ReNu-Hope Counseling will only be providing spiritual guidance and support and will not be providing Clinical Psychotherapy.
I do hereby waive, release, and discharge ReNu- Hope Counseling, from any liability and all injuries, whether emotional or physical, which I might sustain while enrolled in ReNu-Hope Counseling. I do state my intention to waive any such claims and never assert any claim of any motive against ReNu-Hope Counseling services.
I am responsible for any and all indebtedness incurred as a result of services rendered to me or anyone under my guardianship.
I understand that, if, during the course of treatment, the counselor determines that a threat of physical harm to the client or to another person is imminent (including child or elder abuse), the appropriate individuals and authorities will be notified, by law, in accordance with following Florida Statutes: FS 39.201; FS 39.202; FS 39.204; FS 490.0147; FS 491.0147.
I understand that there will be no audio and/or videotaping of a session without my full knowledge and consent.
I understand that my counselor may consult with other professionals on staff and, in so doing, my identity and confidentiality will be protected.
I acknowledge that I have read this agreement, understand its contents and agree to receive services for myself, and/or anyone herein specified, entirely of my own accord.

ReNu-Hope Biblical Counseling Fee Schedule
Online Tele-Counseling allows you to meet with your counselor from your own home,
office, or other location that is convenient for you.
INDIVIDUAL COUNSELING—$80 PER SESSION
50-minute: $80.00 per session

MARRIAGE COUNSELING—$110 PER SESSION
50-minute: $110.00 per session
90-minute: $180.00 per session

PREMARITAL COUNSELING —$100 PER SESSION
1 session per couple: $100.00
5 sessions per couple: $425.00
10 sessions per couple: $850.00

ReNu-Hope Counseling reserves the right to revise this fee scale at any time

Remote Counseling Guidelines & Help

  • In order for your session to be effective, counseling should take place in a quiet, well-lit, private area. For privacy purposes, your counseling space should have a door that can be closed.
  • Your children should be cared for in another area and not present in the counseling space. Unless the session consists within the context of family counseling.
  • You will receive an email invitation to your appointment. This email includes the link needed to connect with your counselor through Zoom. Please have your computer and space prepared for the session 5 minutes prior to the start time.
  • If the power goes off, or an internet/technology-related problem interrupts your session, your counselor will work with you to reschedule or complete the session in the future.
  • During a session, please be sure your cell phone ringer is off and the phone is put away. Commit to not answering the door or another phone during the scheduled appointment. All televisions and music playing devices should be turned off in the session space.
  • Counseling session should be treated as if the appointment is being experienced in the counseling office.
  • After your session, you will receive an invoice for the session via email. Please follow guidelines for payment.
  • Your counselor will work with you to schedule your next session.
  • Please feel free to communicate any issues or complications that arise to your counselor immediately. If your sound or picture quality is poor, please let your counselor know right away.

I hereby agree to the terms and expectations laid out in this document.