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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 Type

Client Information

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Bill To Contact

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Emergency Contact

First Name
Last Name
Street Address
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( If client is a minor, the legal guardian must enter their email address below. )

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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

In order to provide the best service possible and increase treatment success, clients are expected to attend all scheduled appointments. While we understand situations arise and cancellations are sometimes necessary, clients are discouraged from cancelling sessions. Sessions may be changed or cancelled with a 24-hour notice, or the non-discounted session fee of $120 will be due, regardless of your discounted session rate.

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( Full Name )


Effective date: July 15, 2011

Trinity Wellness, LLC, will only release information in accordance with state and federal laws and the ethics of the counseling profession.

This notice describes policies related to the use and disclosure of your healthcare information. Use and disclosure of protected health information for the purposes of providing services. Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes.


Use and disclose health information to: Provide, manage or coordinate care, and/or coordinate or consult with qualified professional consultants and referral sources.


Use and disclose health information to: Verify insurance and coverage, verify income/discount, and/or process claims and collect fees.


Use and disclose health information for: Review of treatment procedures, review of business activities,certification, staff training, and/or compliance and licensing activities.


Mandated reporting, emergencies, criminal damage, appointment scheduling, treatment alternatives, and/or as required by law.


-Right to request where we contact you including home, work, cell, other (please indicate any denial on the intake form).

-Right to release your medical records. We require written authorization to release records to others. Client may revoke release in writing. Revocation is not valid to the extent that you have acted in reliance on such previous authorization

-Right to inspect and copy your medical billing records and other records. Counselor may deny this request and impose charges for copying, mailing, etc. 

-Right to add information or amend your medical records. Clients may request to amend records within 2 days of release. Counselor may deny the request. If denied, client has the right to file disagreement statement which will be filed as part of the client's file along with counselor response. Amendment request must be in writing.

-Right to Accounting of disclosures: For a six year period beginning 2/22/2018. Exceptions: Disclosure for treatment, payment or healthcare operations, disclosures pursuant to a signed release, disclosure made to client, or disclosures for national security or law enforcement.

-Right to request restrictions on uses and disclosures of your healthcare information. Requests must be in writing and counselor is  not obligated to agree.

-Right to complain. Please contact counselor first. If not satisfied, right to complain to the U.S. Dept. of Health and Human Services. There is no retaliation penalty.

-Right to receive changes in policy. Please ask counselor or owner for updated policies. May request any future changes or request to speak to privacy officer (owner).

( Type Full Name )
( Full Name )

Please be sure to complete ALL forms attached to your account.

( Type Full Name )
( Full Name )
Sliding Scale/Reduced Fee

The regular session fee is $120/50 minutes. We offer a few reduced fee spots for clients who qualify. You must provide proof of income. If you are unable to pay the regular session fee, please speak with your counselor to see if there are reduced fee spots available. Please do not let your ability to pay hinder your treatment; speak with Karen Banks or your counselor.

Sessions cancelled with less than 24 hours notice and missed appointments will be charged a $120 session fee, not your reduced fee rate.

You must provide your social security number on the intake form. This information will be used in the event we pursue collection efforts on unpaid accounts.

( Type Full Name )
( Full Name )
Informed Consent

Welcome to Trinity Wellness, LLC. I am looking forward to working with you as you begin this fresh start. It is important to me to co-create a counseling relationship that can help you make the changes you desire and need to make your life and relationships more fulfilling.

Mission Statement

At Trinity Wellness, LLC, our mission is to help clients realize and manage the power they hold within themselves. We strive to help clients manage their mental, physical, and spiritual lives so they may live the full and balanced life they desire. We accomplish this mission by providing counseling, life coaching, and an array of comprehensive wellness services customized for each individual. Our clients are not given advice to follow, they are empowered and educated to become happy, healthy, and successful individuals.

What is counseling?

Counseling is a mutual and collaborative process which means we work together to develop goals that will help you during this phase of your life. Counseling is about change. I am here to help facilitate any changes you desire to make but only you can change yourself. You are responsible for making the effort to work on the problems or issues that concern you. Additionally, counseling works best when we develop a good working relationship, based on mutual trust, honesty, and respect. There are alternative treatments to counseling or psychotherapy, including medication, self-help groups, and self-help guides/books. If you are experiencing any problems or difficulties relating to our sessions, or me, please feel free to communicate those concerns with me.

As your counselor, I consider it a privilege that you chose to share your life and growth with me. I will not hide behind silence or position and will have high regard for you as a person. I will bring the best that I know from my study and experience. I will bring you the highest of my insight, wisdom, and spiritual guidance. You can expect truth from me even when you may not want to hear it. I will always have compassion and empathy for you in all that we do. I value you as a person in need of care.

Counseling Outcomes

No one can guarantee that counseling will produce certain results. There are some risks associated with counseling. For example, you may discover things about yourself that are uncomfortable; sometimes relationships change as a result of counseling; if you are discussing a traumatic event with your counselor, sometimes the feelings get more intense. I am committed to using my professional skills to the best of my ability to address your concerns and help manage possible risks.


I maintain a standard policy of confidentiality. All services are guided by the code of ethics of the American Counseling Association and the laws of the state of Missouri.

Information disclosed within our sessions is confidential and will not be revealed to anyone outside of Trinity Wellness, LLC without your written permission, except under several conditions:

1) If you threaten to harm or kill yourself or another person, I am legally and ethically required to take action to protect the safety of the threatened person. Possible actions could include informing the intended victim, arranging for your hospitalization, notifying family or support system, or alerting law enforcement.

2) If I know or suspect abuse or neglect of a child, an elder person or a disabled person, I am required to report my concerns to the Missouri Department of Social Services.

3) If I am ordered by a court order to testify or share records, I must do so. (This is different from a subpoena from an attorney requesting your records or information. I reply that I cannot comply without consent or court order.)

4) If you name me in a lawsuit.

5) In professional consultation/supervision groups. No identifying information will be disclosed.

Client Responsibilities

For counseling to be successful, the client must take responsibility for their sessions. Clients are expected to:

--Be on time for our meetings.

--Fully participate in our sessions including following through on any homework assigned for in between sessions.

--Be honest, open, and present during our sessions.

--Come to our sessions prepared.

--Pay the fee prior to the session.

--Cancel sessions with a 24-hour notice or pay the full session fee of $120.

Payment and Insurance

At this time, Trinity Wellness, LLC accepts cash, checks, and credit cards. We do not accept insurance.  We will be happy to provide you with a receipt of services to submit for potential reimbursement by your insurer.  Returned checks are $40. The rate for each 50-minute session is $120; 80 min = $150, however, your rate may be lower based on a sliding scale. There are limited spots available at each reduced rate and the reduced rate is only offered for a limited number of sessions.

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( Full Name )
Contractual Agreement for Documentation and Court Appearances

Clients are discouraged from having their therapist subpoenaed or having her provide records for the purpose of litigation. Even though you are responsible for the testimony fee, it does not mean that my testimony will be solely in your favor. I can only testify to the facts of the case and to my professional opinion. Any letters or statements can be descriptive, not interpretive.

If you request that your therapist meet with your attorney, and or make a court appearance on your behalf (or if an appearance is required by subpoena) your therapist may be required to clear the entire appointment calendar for that day or for a block of time. To accommodate your need for the therapist's appearance and testimony, and to adequately prepare and review any necessary documents and records, the following guidelines apply:

- Scheduling a court appearance must be done at least one week in advance of the court date, and payment for the minimum charge is due at the time of booking.

- For your therapist to meet with your attorney at our office schedule a regular session time ($120/50 minutes). To arrange for your therapist to meet at your attorney's office, a prior appointment must be made, and therapist fees include travel time to and from our office.

- Fees for an appearance or a consultation with therapist are $250 per hour, including travel, waiting for court, meeting with your attorney, and/or actual testimony time.

- There is a minimum fee of 4 hours ($1,000.00) required for any court testimony or appearance of a therapist, regardless of the actual time spent, or if the case is cancelled or postponed when the therapist arrives in court/attorney's office.

- The fee to block an entire day of the therapist's time from 8:00 a.m. to 6:00 p.m. is $2,160.00.

- Unless you have the therapist block an entire day for court appearance, your therapist will estimate an amount of time reasonable to accomplish the court appearance you are requesting. If your case is postponed or delayed on the day of appearance, and you have not guaranteed your therapist's presence for the entire day, the therapist will only be available for the estimated time.

- If the court appearance is cancelled less than four (4) days prior to the appearance, the minimum fee of 4 hours will apply.

- Other fees:

o Writing a treatment summary $50-250

o Writing a letter $60

o Retrieval fee for records: $24.50 + $0.50 per page

o Mileage: $0.53.5

o Filing a document with the court: $100

o All attorney fees and costs incurred by the therapist

Please note:

All fees are doubled if therapist had plans to travel out of town or close office for vacation.

If court case is located outside of 50 mile radius of counselors office, above fees are doubled.

Client agrees to pay hotel fees if counselor is staying overnight due to case time restraints.

Fees are in alignment with Missouri state standards medical records (

A minimum of 72 hours notice of any court appearance is necessary so that schedule changes for clients can be made within a reasonable time frame.

If the therapist is to receive a subpoena, then the attorney or office staff is required to call her office and set up a time for the subpoena to be served during office hours. Example Letter: "Client X has participated in 12 sessions of counseling with me. During these sessions she has reported trouble waking up in the morning, feelings of despair, and a difficulty completing everyday tasks. She reports that her symptoms are making it difficult for her to attend class. Following the guidelines of the DSM-V, I have diagnosed Client X as having Major Depressive Disorder." 

A retainer of $1500 is due in advance. The remainder of the costs will be billed after the court appearance and will be due upon receipt. 

If a subpoena or notice to meet attorney(s) is received without a minimum of 72-hour notice there will be an additional $250 "express" charge. Also, if the case is reset with less than 72 business hours notice, then the client will be charged $500 (in addition to the retainer of $1500). If the therapist is subpoenaed and the case is reset with less than 72 business hours notice prior to the beginning of the day of the scheduled subpoena, trial, then the client will be charged $500 (in addition to original retainer of $1500 for having to appear in court). 

Any refund from the retainer owed to the client will be remitted by mail to the client's address of record no less than 30 days after completion of the court appearance.

If I see both a husband and wife separately, there is an obvious conflict of interest. I would rather not damage the trust I have built in the counseling relationship with each client especially if I am still seeing that person for therapy.

My signature below signifies that I have read, understood, and agree to abide by all terms outlined in this contract, as well as providing my consent for Trinity Wellness/my therapist to release records and/or testify verbally and/or in writing to counseling services received in specific conjunction with said court appearance.

( Type Full Name )
( Full Name )