Securely share your information to begin your journey toward support, clarity, and lasting change.

Confidential New Client Form

This confidential form is designed to help Dr. Randy Moraitis better understand your situation, needs, and goals before your first session. All information submitted is kept private and handled with the highest level of care and professionalism.

Completing this form allows us to make the most of your time and ensures that you receive the most appropriate support, whether you are seeking counseling, recovery coaching, or intervention services. Please take a few minutes to fill out the form as thoroughly as possible.

Today's Date *

Name *

Date of Birth *

Age *

Address *

City *

Zip *

Home Phone *

Work Phone

Cell Phone

Do I have your permission to leave a voicemail message at these numbers? *

What is the best number to reach you at? *

Occupation *

Employer *

Highest Grade Level *

Height

Weight

Marital Status

Spouse's Name

Spouse's Age

Children's Names and Ages

Who may I thank for referring you?

Please answer honestly. All answers are strictly confidential.

Current medications and purpose: *

Substances used page 30 days: *

Prior substances used (alcohol or drugs): *

Age of first sexual experience / contact: *

Have you ever been sexually abused? *

Have you ever been physically abused? *

Previous therapy, counseling, or coaching (place / length): *

Have you ever attempted suicide? *

Have you ever had suicidal ideas / thoughts? *

Feelings towards mother: *

Feelings towards father: *

Siblings: *

Other significant relationships: *

Religious / spiritual affiliation: *

Current occupation / grade level: *

Describe your reasons for coming to counseling or coaching: *

State your goals for counseling or coaching: *

Fees and Payment

Session Rate: $200*(Coaching clients may pay by package).
The session rate is based on a 50 minute session.
Payment is expected at the time of session unless prior arrangements are made.
There will be a $25 administrative fee for any returned checks.
The hourly rate will be billed for any type of extra administrative work (i.e. a letter for a Judge, or a PO)
Dr. Randy Moraitis does not take insurance at this time, however, some clients may deduct their coaching fees on their taxes. Contact your accountant to inquire.
If for any reason there are outstanding/unpaid session fees, a collections service may be utilized.
*If you are unable to afford this fee, you may apply for a reduced fee.

Cancellation Fee

Cancellation must be made 24 hours in advance. I understand that if cancellation is made less than 24 hours in advance for any reason I will be charged the regular session rate.

Consent / Release of Liability

I, ______________________________ am willingly and voluntarily entering into counseling and/or professional coaching, and/or intervention services with Randy Moraitis, PhD, CIP, BCPC, CADC II, ICADC. I hereby voluntarily assume any and all risk of injury, mental, spiritual, emotional, physiological and/or physical harm, any personal loss and/or damage resulting from my personal counseling with Randy Moraitis, PhD, CIP, BCPC, CADC II, ICADC. Randy is a Board-Certified Diplomate of Positive Neuropsychology, Board-Certified Licensed Pastoral Counselor, Certified Drug and Alcohol Counselor, Certified Life Coach, Certified Recovery Coach, and Board-Certified Intervention Professional.

I agree to the Consent / Release of Liability (Type Name) *

Confidentiality Agreement

Confidentiality means that whatever is shared between client and counselor remains between client and counselor. Additionally, it is the client’s choice to share with other’s that they are seeing a counselor.

The only times that this confidence can be broken is in the event that the client reveals to the counselor that they want to hurt themselves or another, or have been involved in the abuse of a minor or elder.

Limits of communication outside session
Voicemail, email, and texting: are a means to communicate specific details such as scheduling or canceling an appointment. They are limited interactions and not a form of counseling.

Phone calls: any phone call exceeding 10 minutes is subject to prorated hourly billing. In some cases, “Phone Sessions” or “Facetime” may be prearranged.

Any type of social media interaction is not a form of counseling and is not a confidential setting.

I understand confidentiality and the limits of communication outside of counseling sessions.

Coaching Package Info

Coaching packages are intended to gain a full commitment from the client and are therefore not refundable. If the client is unable to complete the sessions in the package, they are transferrable within the client’s family.

Credit Card Payment Release

Using your credit or debit card is one option for paying the counseling session fees. Filling out this form gives Randy Moraitis permission to run your card. Your card will never be charged without your permission or knowledge, and this information will always remain secured in your file.

Credit card number:

Expiration date:

CCV / CVV code:

Zip code of billing address:

Randy Moraitis has my permission to run my credit / debit card:

Signature:

Date:

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