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Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Client Information

/ Middle Initial


( for Text Message Reminders )

Bill To Contact

/ Middle Initial

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )

Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )

( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

Cancellation Policy
Attendance is fundamental to good therapy. The time we put aside for therapy is important. Consistent sessions allow for the best progress and growth. However, life happens and it is sometimes necessary to cancel or reschedule sessions.

If you fail to cancel a scheduled appointment, I cannot use this time for another client.

The expectation is that if you have to cancel an appointment that you will contact me via phone, text or email as soon as possible. In the event you do not notify me of a cancellation (no call/no show), you will be charged for the missed appointment. The only exceptions to this are cancellation due to illness or cancellation due to emergencies.

For clients working through insurance or full fee private pay, you will be charged the full session fee ($150) for no call/no show appointments. For clients working with a multi-session package, you will be charged a session from that package.

An invoice will be sent via email and regular mail. Your prompt payment for the missed session is appreciated.

Thank you for your consideration regarding this important matter.

Erik Young M.Ed., LPC
Erik Young Counseling LLC

Client Signature (Client’s Parent/Guardian if under 18)

Today's Date
( Type Full Name )
Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:
Duty to Warn and Protect

When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

Abuse of Children and Vulnerable Adults

If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.
Prenatal Exposure to Controlled Substances
Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.


Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.
Insurance Providers (when applicable)
Insurance companies and other third-party payers are given information that they request regarding services to clients.

Information that may be requested includes, but is not limited to: types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries.
I agree to the above limits of confidentiality and understand their meanings and ramifications.

Client Signature (Client’s Parent/Guardian if under 18)
Today’s Date
( Type Full Name )
All payments are due at the beginning of the session. Cash, check and credit cards are accepted in the office. You can also pay online for sessions and multi-session discount packages at
( Type Full Name )
Social Media Policy
Social media is a fact of modern life. I participate in social media professionally and personally. I encourage you to "like" my professional sites on facebook, twitter, pinterest and instagram. That will allow you to get my various articles and special offers before everyone else. You may also connect with me on my personal site. I will not identify anyone as a client and as such will not respond to or encourage any interactions/questions that may be considered therapy or are connected with your therapy. You may direct any therapy related queries through the hipaa compliant email located on this site or through the private messenger app of your choice.
( Type Full Name )
For clients who purchase multi-session packages, refunds will be issued under the following circumstances.

Refunds will only be issued for unused sessions if therapy is formally terminated. Termination needs to be done in writing. A check for the balance of the unused sessions will be issued within 90 days of written notice of termination of therapy.
( Type Full Name )