I understand that Dr. Sullivan counsels from a Christian perspective and may use
Christian principles while integrating counseling theories to treat you. I understand that I am consenting to treatment and have read the policy letter and
that my records will remain at Grace Counseling. Dr. Sullivan is a Board Certified
Christian Counselor and a Board Certified Human Services Practitioner. He is an
ordained minister. Grace counseling does not process insurance.

Male/Female Policy:
Dr. Sullivan will meet with female clients with a female staff
member available in a nearby room.

I understand that payment is required when services are rendered and that I am
responsible for all charges. I also understand that unless I give a 24 hour notice to
cancel an appointment, I will be financially responsible for the charge of the missed
appointment. If you need to cancel an appointment when the office is closed, leave a
message with the number provided. A session is defined as 50 minutes. When a
session continues beyond that point and reaches a second hour, your fee becomes
an hourly rate and you will be responsible for the additional charges. Given the
nature of the counseling relationship, there will be times when you may see your
therapist in public, call or text message them. Whenever you or the therapist
recognizes that you are using these personal times for the purpose of receiving
counsel, you should plan to count that time as a session(s) and apply the appropriate
session fee(s).

We understand that personal problems are very difficult to talk about. That is why
confidentiality is extremely important to us. We take every precaution to protect the
confidentiality of your visit with us.

Unless you give us written permission to do so, we do not discuss your situation with
anyone except for the reasons cited below:

1) If we learn about child, adolescent or elder abuse or abuse of disabled
persons, we are required by law to report it to the proper authorities.

2) If, in our judgment, a client is dangerous to himself or others (suicidal or
homicidal), we will disclose information in order to help protect persons
from harm.

3) If we are required to present records or witness testimony, to comply with a
court order, we are legally responsible to comply. The cost for Dr. Jon
appearing in court is $500 per hour with a minimum charge of 3 hours by
certified check paid prior to court appearance.

This provides a safe and secure opportunity for you to discuss personal problems with
us. Weapons are not permitted in the Grace Counseling office.

I have read and understand all of the above and I have received a copy of the HIPAA
Notice of Privacy Practices. In the event that I cannot reach my therapist, and I
have an emergency, I will call 911.