Court-Ordered Counseling Consent and Intake Form

Counseling Consent

I acknowledge that I am required to participate in counseling as mandated by the court. I consent to the counseling process, understand its purposes, and authorize communication with court representatives as required by law.

I consent and agree to the terms above

Client Information

Full Name

Date of Birth

Address

Phone Number

Email Address

Court Information

Case Number Court Name Judge's Name Reason for Court-Ordered Counseling

Emergency Contact

Name Phone Number Relationship

Current Concerns

Please describe your current concerns and goals for counseling

Confidentiality Agreement

I understand that information shared during sessions will remain confidential, except where disclosure is legally required (such as harm to self or others, or as mandated by the court order).

I have read and understand the confidentiality terms

Signature

Signature Date