Client ID Form

 Information and Consent ID Form 17

Identification Information

        Thomas Arbaugh, Ph.D.

 

 

Name: ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­________________________________   Birthdate: __________________

 

Address: _____________________________________

               _____________________________________

               _____________________________________

 

Home Phone: ________________________________

 

Mobile Phone: ________________________________

 

E-mail:                         ________________________________

 

Emergency Contact Information:

 

Person ______________________________________  Relationship ________________

 

Phone: ______________________________________

 

 

Important Information:

            I understand that although Tom Arbaugh holds a PhD in Counseling, he is no longer doing counseling or psychotherapy. He does not do treatment plans, assessment, or clinical documentation. Dr. Arbaugh does not receive third party reimbursements.  Integrative Dialogue is a time for open communication between two or more of us in an effort to help make my life better through personal growth. Any counseling, psychotherapy, or psychopharmacology that I might want or need will be referred to a licensed professional.

I wish to hire Tom to consult with me and dialogue about any life issues that I bring for his attention. It is my understanding that he will also dialogue from his life experience in an effort to help me lead my life more fully.

The undersigned has read and understood the above statement and has had an opportunity to ask questions and seek clarity at any time during ongoing dialogue.

 

 

 

___________________________________________          ____________________

Name                                                                                       Date

 

 

 

____________________________________________        _____________________

Name                                                                                       Date

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