Please print off the following forms

and fill them out before our intake.

Informed Consent & Disclosure Statement

Includes information about my training and credentials, the limits of our relationship and your rights as a client

Statement of Fee Policy

Includes information about extra phone calls, auxiliary services, and emergencies, as well as scheduling and cancelations.

The forms above support both of us during our time together.

I realize these are lengthy and I appreciate the time you take in reading and filling these out.

Release of Information Form (ROI)

This is a Release of Information, which allows select parties to discuss your situation. The information exchanged during therapy is confidential; therefore, your consent is required to discuss it with outside parties (such as schools, doctors, etc.)

Genuine Heart Counseling, LLC

Chandra Lontz-Smith, MA, LPC


16 Mountain View Ave, Suite 112

Longmont, CO, 80501

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