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.




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Name                                                                                       Date




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Name                                                                                       Date