I, have been fully advised of my rights to confidentiality under Michigan Law and under the Federal Privacy Act of 1974. I elect to waive my privilege against the disclosures of my record and authorize:

to share information with Grand Rapids Counseling Services. This exchange of information is authorized only for the purpose of providing sufficient background information to assist in the assessment, education, or counseling progress at Grand Rapids Counseling Services, providing the court with counseling progress at Grand Rapids Counseling Services, and providing the court with verification of the client's information as disclosed is prohibited unless consistent with the authorized purpose stated above. Any persons receiving such information shall be advised. The waiver is effective until the purpose for which it was written no longer exists.

CANCELLATION POLICY: All clients must provide 24 hour advanced notice to reschedule appointments, failure to do so will result in a $50 cancellation fee. Fifteen (15) minutes late for an appointment is considered a cancellation.