MyCounselingSpace

By using My Counseling Space services, you agree that:

1. You are 18 or older and not currently in therapy with any other licensed therapist. If you are under psychiatric care for medications, you have talked with your doctor to inform her/him that you are seeking additional help;
2. You are not feeling suicidal and/or self-destructive;
3. You are not under the influence of alcohol or drugs;
4. You are not being treated for Schizophrenia;
5. You are the authorized user of the credit card or have the owner’s permission;
6. If your problem would be better discussed in person, we will help by making a referral;
7. You have read the privacy statement and you have a general understanding that there are some limits regarding privacy on the Internet.
8. You are aware that others may view your therapy sessions on your home or office computer and you have taken any measures you feel you need for your own protection of this material.

Required Field


I agree that I have read the information above:	YES NO
I agree that I have read the privacy statement:	YES NO
First Name:
Last Name:
Address:
City:
State:
Zip:
Email address:
Phone:
Questions/Comments Electronic Signature: By entering your name below you are signing this document electronically as outlined in the Internet and Telecommunications Policy. Your correct signature is required before continuing.

My Counseling Space is excited to be able to offer you the most convenient way of counseling right from your computer through the internet!