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Arizona, USA

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📝 Informed Consent for Counseling Services

Provider: Roy D. Chukwuemeka, LPC
Practice Name: Zoe Integrated Wellness, PLLC
Contact: : zoewellness07@gmail.com

Phone: 928-275-7277
Effective Date:  October 8, 2025

📘 Purpose of Counseling

Counseling is a collaborative process where you and your therapist work together to explore concerns, develop coping strategies, and promote emotional wellness. Sessions may include discussion of personal history, emotions, relationships, and goals.

🧠 Nature of Services

  • Services are provided by a Licensed Professional Counselor.

  • Modalities may include cognitive-behavioral therapy, trauma-informed care, narrative therapy, and other evidence-based approaches.

  • Sessions may be conducted in-person or via HIPAA-compliant telehealth platforms.

🔐 Confidentiality

Your privacy is protected under HIPAA and state law. Information shared in sessions is confidential except in cases involving:

  • Risk of harm to self or others

  • Suspected abuse or neglect of minors, elders, or vulnerable adults

  • Court orders or legal mandates

⏳ Duration & Frequency

Sessions typically last 45–60 minutes. Frequency is determined collaboratively based on your needs and goals.

🧾 Fees & Cancellation

  • Session fees:

  • Initial Consultation $100

  • ​Anxiety/Depression $ 110

  • Trauma $120

  • Cancellation  50% of session fee 

  • Cancellations require 24 hour notice to avoid charges.

✅ Consent

By signing below, you acknowledge that you understand the nature of counseling, its risks and benefits, and your rights as a client. You consent to participate voluntarily and may withdraw at any time.

Client Name: _______________________________________
Signature: __________________________________________
Date: _________________

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Client Intake Questionnaire

Please complete this form prior to your first session. Your responses help tailor therapy to your unique needs.

👤 Personal Information

  • Full Name: ______________________________________

  • Date of Birth: _______________ Age: ______

  • Phone Number: ___________________

  • Email Address: ___________________

  • Emergency ContactPeron's name and phone:  ______________________________________________________

🏠 Living Situation

  • Who do you live with? __________________________________

  • Any recent changes in housing or relationships? ____________

💬 Presenting Concerns

  • What brings you to therapy at this time?

  • How long have these concerns been present? _______________

🧠 Mental Health History

  • Have you received counseling before? □ Yes □ No
    If yes, when and for what reason? _________________________

  • Any history of psychiatric hospitalization? □ Yes □ No

  • Current medications (mental health or otherwise):

❤️ Emotional Wellness

  • How would you describe your current mood? _______________

  • Any recent experiences of grief, trauma, or loss? ____________

  • Do you have thoughts of self-harm or suicide? □ Yes □ No
    If yes, please explain: _________________________________

🙏 Spiritual/Cultural Identity (Optional)

  • Do you identify with a particular faith or spiritual tradition?

  • Are there cultural values or practices important to your healing?

🎯 Goals for Therapy

  • What would you like to achieve through counseling?

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