Counseling Disclosure Form

If your session will be over the telephone please signature and date this document and mail to:

Stefan Schlesinger
8401 5th Ave NE, Suite103
Seattle WA. 98115

I request that my treatment records will contain only the following information

1. client name
2. fee arrangement and payment record
3. date(s) service rendered
4. disclosure form signed by counselor and client

My signature below indicates that I

1. Have read and been given a copy of the disclosure statement provided by
   Stefan Schlesinger and understand the terms describe therein;
2. Understand the services offered and requested and authorized them under my own free will reserving to terminate services at any time;
3. Have received the a copy or read online Washington's State Department of Health’s information brochure for counseling clients;
4. Agree to allow Stefan Schlesinger to consult professionally if needed about the general and specific details of my therapy

Client Signature		Date
Counselor Signature		Date