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  • About Us
  • Services
  • Payment and Fees
  • Clinician Bios
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  • Contact Us
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    • Home
    • About Us
    • Services
    • Payment and Fees
    • Clinician Bios
    • Intern Clinic
    • COVID-19 Response
    • Employment Opportunities
    • Forms & Notices
    • Directions
    • Resources
    • Blog
    • Black Lives Matter
    • Contact Us

  • Home
  • About Us
  • Services
  • Payment and Fees
  • Clinician Bios
  • Intern Clinic
  • COVID-19 Response
  • Employment Opportunities
  • Forms & Notices
  • Directions
  • Resources
  • Blog
  • Black Lives Matter
  • Contact Us

CLIENT FORMS & NOTICES

You will be asked to fill out and sign some of the documents below during your first visit.  

Your therapist will send you a link to our Client Portal to complete and sign forms electronically.  If you have any questions about our forms, please do not hesitate to call or email: jacob@ercounseling.com.

Registration Form (pdf)Download
ERC Professional Service Agreement 9.13.2022 (pdf)Download
ERC Fee Schedule 4.11.22 (pdf)Download
ERC Notice of Privacy Practices 3.8.22 (pdf)Download
Insurance Information (pdf)Download
Debit/Credit Card Consent (pdf)Download
No Surprises Act Notice (pdf)Download

OTHER FORMS

Release of Information (pdf)Download

Copyright © 2022 Empowering Relief Counseling, PLLC - All Rights Reserved. Updated: 09. 28.2022


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