Office Policies

Please print, read, sign and fax: (479)253-4991
or mail this form to The Center for Peace in the Family, 2580 CR 3027, Eureka Springs, AR 72632

The Center for Peace in the Family is located in the United States, in the State of Arkansas. David W. Reuter MS, LPC is licensed as a Professional Counselor by the State of Arkansas. Counseling performed at a distance (such as over the telephone) will be considered to take place within the State of Arkansas, regardless of your location as client, and will be governed by the laws and ethical requirements of the State of Arkansas. Since Arkansas has legal and ethical standards that are among the highest in the U.S., this both protects our clients and creates a clear standard for our counseling sessions.

Arkansas Counselors are required to maintain strict confidentiality of all information disclosed in your session. Contact information and records pertinent to telephone counseling sessions are physically maintained in our office as required by law. Records are not maintained electronically on a server or network.

Telephone sessions are as secure as you can make them as we have no control over your telephone extensions or your use of remote receivers, and have no means of detecting wire taps on your telephone lines and equipment. We do not use remote phones, do not record telephone sessions, and we do not agree to have telephone sessions recorded.

We will not reveal any information from your sessions without your consent in writing, except where otherwise required by law. Those situations would include the following:

If the counselor determines you are a serious danger to yourself or others, or "gravely disabled", i.e. unable to care for yourself, the counselor is required to break confidentiality to protect you, or protect others from you.

If you disclose child or elder abuse, the counselor is required by law to report this to the appropriate authorities.

If the counselor's records are subpoenaed by a court of law, or the counselor is otherwise ordered by the courts to break confidentiality, the counselor is required to obey the law.

Communication by e-mail can at times be helpful in sharing information that is relevant to the counseling process. However, communication by regular e-mail cannot be considered secure and therefore may only be used for sharing general information that does not require confidentiality. If you choose to communicate or receive information from us by e-mail, your e-mail address and any other identifying information will not be sold, rented, bartered or otherwise willingly shared with any other organization, group, individual, or entity.

I (we) have read the above Office Policies, understand them, and agree to them in full.

______________________________________________________________________ 
Client Name (Please Print) Additional Client Name (Please Print) (for couples) 
______________________________________________________________________ 
Client Signature/DateAdditional Client Signature/Date 

Confidential Client Information

CLIENT'S NAME ________________________________ DOB __________ Age ___ Sex ___

___Minor ___Unmarried ___Married ___Separated ___Widowed

Address________________________ City___________________ St____ Zip______

Home Phone (___)___________ Work (___)___________ Cell (___)___________

E-mail____________________________ Occupation____________________________

Soc. Sec. # _____________________ Religious Affiliation________________________

SPOUSE'S/PARENT'S NAME _____________________________ DOB ______Age ___ Sex ___

Home Phone (___)____________ Work (___)___________ Cell (___)___________

E-mail__________________________ Occupation____________________________

Soc. Sec. # _____________________ Religious Affiliation_______________________

AUTHORIZATION FOR COUNSELING AND FINANCIAL AGREEMENT

I authorize the counseling of the person(s) named above and agree to pay all fees and charges for such counseling prior to the time of service.

I understand that I will be charged for cancellations made less than 24 hours in advance. I will be fully responsible for such charges.

Signature: _________________________________________ Date_____________

Signature: _________________________________________ Date_____________

[For Couple/Marital or Family Counseling both partners/parents must sign]

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