Our Student Counselors provide no-fee counseling for the duration of their time with us. To meet the requirements of their programs, we are required to record some or all of their sessions. You will be asked to sign a consent form to allow for this recording, which will only be shared with the student's supervisors.

I understand that I will be aksed for my consent to record some or all of my sessions.

Type of Session *

I am interested in on-line sessions and acknowledge that I will need to be in the state of PA for my online video sessions.

I am only interested in in-person sessions.

I can do in-person or online sessions.

Legal Client Name *

First Name

Last Name

Phone

(###)

###

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Life Balance will not be able to provide sessions with our no-fee student counselors if consent is not given to record sessions. *

I acknowledge

Life Balance student counselors work under the supervision of Michelle Jones, LCSW and Marlo Ann Torrelli, LPC *

I acknowledge

Life Balance student counselors work with us for a limited amount of time (normally for one semester). After that time, you will be given referrals for another therapist in the community or may also choose to transfer to a different therapist at our practice if one is available. If you choose to continue treatment after your time with our student counselors, normal rates will typically apply.

I acknowledge