Ken-Lyn’s National Family Counseling Services
Primary Client Agreement Form

First Name

Last Name

Date of Birth

Social Media Handle/Type (Facebook, Twitter, Etc.)

1.) KENLYN SERVICES: I have reviewed the information made available about Ken-Lyn Consultant and Associates via an initial consultation, information online and I am content with their mission, reviews and services as indicated (website, Facebook, etc.).

2.) CONFIDENTIALITY: I understand that Ken-Lyn will provide a confidential environment and no information shared inside of counsel will ever be provided to anyone or any entity with the exception of bodily harm, suicidal tendencies, rape/molestation or youth related harm and will be handled on a case-by-case basis. All youth-based counseling is considered “family counseling” and pertinent information may be shared, again on a case-by-case basis. Additionally, I understand that Ken-Lyn’s staff will only be exposed to information for filing and/or for billing purposes.

3.) IMAGE/LIKENESS APPROVAL FOR USE: It is Ken-Lyn’s practice to create tailored counseling slide presentations in the form of lessons occasionally during our time together. I consent to allowing Ken-Lyn to pull pictures, videos or graphics from your social media for the EXCLUSIVE purposes of inner counseling services AND never to be used for advertisement or any other purpose then for the personalized sessions intended.

4.) FEE SCHEDULE: I agree to the payment structure as listed below per each relevant service for me/my family. Occasionally, there has to be an annual/bi-annual increase to cover raised rental, insurance rates, and related business expenses.

5.) PAYMENT: Payment is due upon service rendered. Clients are asked to pay immediately after our session or agree to allow for payment within 48 hours after services have been rendered via electronic payment from the stored credit card.

6.) OPTIONAL: Ken-Lyn is a Teaching Counseling Firm: Vetted interns work at Ken-Lyn. Only with your initialed consent, an intern may be allowed to sit in as an observer (no input, no inclusion) to aid them with preparing to become a bona-fide counselor. Would you mind if an intern observes an occasional session?

PER OUR YOUR INITIAL CONSULTATION:

I hereby agree to the terms cited in this document and agree to render payment electronically on or no later than 36 hours after the time of service. I agree to allow my Credit Card to be kept on file and processed if payment is not rendered after 36 hours. My financial terms are as follows as agreed to during the initial consultation:

A. Service(s) that will be Rendered – Describe (individual, couples, First Fratt, etc.)

Insurance

B. Agreed Upon Session Fee Per Session (fill in your fee)

First Fratt Fees: $25 per month (May and June)

C. Agreed Upon Registration Fee

First Fratt Fees: $0 Registration Fee

Do you have MILITARY insurance?

Yes

Do you have OTHER insurance?

Yes

Military Insurance:

Benefits Number

Insurance:

Identification/Policy Number

Tricare Referral/Diagnosis

Upload File

Upload supported file (Max 15MB)

Military ID Card (Front/Back)

Upload File

Upload supported file (Max 15MB)

Credit Card Information

Card Type:

MasterCard

Visa

Discover

AMEX

OTHER

Cardholder Name (as shown on card):

Add answer here

Card Number:

Expiration Date:

Cardholder Zip Code

3-Digit Code

CONSENT: Courtesy Cancellation Fee/No Show Fee (client fails to honor appointment within 48 hours of the date of service) - $75

Signature Line: I agree to the terms and conditions as stated above. I also authorized Ken-Lyn Consultants to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

Client Responsible for Payment

Date

Thank You for Submitting!

Ken-Lyn’s National Family Counseling Services
Primary Client Agreement Form

First Name

Last Name

Date of Birth

Social Media Handle/Type (Facebook, Twitter, Etc.)

PER OUR YOUR INITIAL CONSULTATION:

A. Service(s) that will be Rendered – Describe (individual, couples, First Fratt, etc.)

Insurance

B. Agreed Upon Session Fee Per Session (fill in your fee)

First Fratt Fees:

*In-Person monthly service Fees---$25

**In-Person and Online Tutoring fees to be discussed with FF Leadership**

C. Agreed Upon Registration Fee

First Fratt Fees: $0 Registration Fee

Do you have MILITARY insurance?

Yes

Do you have OTHER insurance?

Yes

Military Insurance:

Benefits Number

Insurance:

Identification/Policy Number

Tricare Referral/Diagnosis

Upload File

Upload supported file (Max 15MB)

Military ID Card (Front/Back)

Upload File

Upload supported file (Max 15MB)

Credit Card Information

Card Type:

MasterCard

Visa

Discover

AMEX

OTHER

Cardholder Name (as shown on card):

Add answer here

Card Number:

Expiration Date:

Cardholder Zip Code

3-Digit Code

CONSENT: Courtesy Cancellation Fee/No Show Fee (client fails to honor appointment within 48 hours of the date of service) - $75

Signature Line: I agree to the terms and conditions as stated above. I also authorized Ken-Lyn Consultants to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

Client Responsible for Payment

Date

Thank You for Submitting!

Ken-Lyn’s National Family Counseling Services Primary Client Agreement Form

Insurance

Credit Card Information

Signature Line: I agree to the terms and conditions as stated above. I also authorized Ken-Lyn Consultants to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

Ken-Lyn’s National Family Counseling Services Primary Client Agreement Form

Insurance

Credit Card Information

Signature Line: I agree to the terms and conditions as stated above. I also authorized Ken-Lyn Consultants to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

Ken-Lyn’s National Family Counseling Services
Primary Client Agreement Form

Ken-Lyn’s National Family Counseling Services
Primary Client Agreement Form