New Client Form Name First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country How did you hear about Laura Rain? * What is your intention for your sessions? * Are you under a physician or mental healthcare provider's care for anxiety, depression, or any other diagnosis? If yes, please explain: * Payment and Cancellation Policy: Payment is expected at the end of service. A $65 missed session fee may be assessed if you cancel in less than 24 hours. The full session fee may be charged if you "no-show" your appointment. I understand that Laura Rain is an ordained spiritual counselor providing holistic, mindfulness-based services. I understand Laura Rain is not a licensed mental health counselor and is not offering mental health services. I agree to hold Laura Rain harmless and not liable for any and all claims that may arise. I agee to the payment and cancellation policy. Guardian Consent for Minors If the client is a minor, I give permission for Laura Rain to provide holistic spiritual counseling services to my child. Signature * (Type Signature) The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforce-ability and admissibility. Date MM DD YYYY Thank you!
