JUNO COUNSELING AND WELLNESS

By Vassilia Binensztok, PhD

Forms & Policies

INFORMED CONSENT FORM

This document will inform you of your rights as a client. This includes the confidentiality agreement.

Download Informed Consent

INTAKE FORM

The questions on this form will help me get to know you better. The information on this form is confidential.

Download Intake

RELEASE OF INFO

This form is used to release your protected health information as required by federal and state privacy laws.

Download Release of Information

EMERGENCY CONTACT INFORMATION FORM

Emergency Contact Information Form. This information will be extremely important in the event of a medical emergency.

Download Emergency Contact Information

EMERGENCY POLICY

If you are experiencing an emergency, considering harming yourself, or harming someone else, please call 911 immediately. Please be aware that the Juno Counseling Center does not have a crisis hotline and is not equipped to handle acute crises. We are not liable for any emergencies reported to us through this contact form, business voicemail, email, or social media pages. Dial 911 for all emergencies.