Client Forms

We look forward to meeting you! Please print and complete these forms and bring to our first appointment.

For couples, please fill out one consent form and an intake for each person.

Mike Dawson’s Forms:

Fully Living Intake Form

Fully Living Consent Form

Fully Living Consent Form.

Michael Dawson, MA, LPC
Christian and Traditional Counseling
www.fullylivingnow.com
1190 Parker Square, Flower Mound, TX 75028
972-523-1235
Fully Living
Living
ully Living
Living
Confidential Client Consent
Welcome to Fully Living!
My goal is to assist you in achieving solutions to your problems and experience healthy, satisfying relationships that will add meaning and purpose to your life. It has been shown that more favorable results are achieved in therapy when clients have a good understanding of the therapy process. Please read the following information so you may be able to make an informed consent to the counseling process. Please ask regarding any questions you may have.
Therapist
My name is Michael (Mike) Dawson, MA, LPC, a Licensed Professional Counselor in the State of Texas, doing business as Fully Living Counseling PLLC and Flower Mound Counseling PLLC. I provide mental health care services to adult individuals and couples for a variety of issues. I earned my Masters degree in Marriage and Family Counseling at Southwestern Seminary in Fort Worth Texas, along with a Masters in Christian Education.
Benefits and Risks of Therapy
Counseling is both an art and a science. Many individuals show great benefit from counseling, although results cannot be guaranteed. People come into therapy with various problems that cause internal distress and relational issues. Often, growth may not occur until you experience and confront uncomfortable issues that may make you to feel sadness, sorrow, anxiety, or pain. Sometimes changes made during the therapy process effect other relationships such as family, friends or in the workplace. The success of the therapeutic relationship depends on the quality of mutual efforts.
Client involvement- Much of the success in achieving goals in therapy rely on you to take responsibility for certain things. It has been shown that patients who actively work on their concerns both in session and outside, and take responsibility for changing their own thoughts, feelings and behaviors are more likely to achieve their goals and receive more benefit from counseling than those who do not. Keeping all scheduled appointments and being on time is very important. Being open, honest and active in sessions is essential also.
Counselor involvement- An initial assessment at the first session will be conducted, along with an ongoing assessment of the nature of your concerns and problems. A therapy plan including goals and the processes for achieving them will be developed.
Treatment
I provide Christian and traditional counseling. My personal belief is that Spiritual principles speak to meaning, purpose and change needed in order to achieve healthy relationships with others, God and also to the individual themselves. Christian principles used in the therapeutic process are always done in a non-coercive manner. Although many forms of therapies may be used, I mainly utilize cognitive-behavioral therapy since many problems are rooted in history or current thinking. This therapy involves the teaching of principles for practical living, modeling, skills training, restructuring and problem solving. For couples I mainly use the Gottman Method of Couples Therapy.
The Therapy process generally includes: 1) a beginning which includes getting to know one another, identifying problems and determining what is desired to be achieved; 2) a middle involving plans and activities, and developing solutions; and 3) an ending where evaluating the attainment of goals and after care goals are considered.
Length of Therapy- The number of sessions depends on many factors and will be assessed and discussed with you. Therapy sessions are 45-50 minutes in length. Double sessions or intensives (4-8 or more sessions) can be scheduled for couple or marriage counseling as necessary.
Michael Dawson, MA, LPC
Christian and Traditional Counseling
www.fullylivingnow.com
1190 Parker Square, Flower Mound, TX 75028
972-523-1235
Fully Living
Living
ully Living
Living
Discontinuing Treatment
I hope that you will see therapy through all of these phases, but it is important to understand you have the right to terminate therapy at any time and agree to notify me immediately so I may provide you with referrals for continued care.
Alternative Treatments- There is a variety of other services available to you that work in conjunction with, or in place of counseling. I can assist you in determining the applicability to alternative treatments.
Consumer Information- An individual who wishes to file a complaint against a Licensed Professional Counselor may write to: Complaints Management and Investigative Section; P.O. Box 141369; Austin, Texas 78714-1369; or call 1-800-942-5540 to request the appropriate form or obtain more information.
File Retention- In the event this counseling practice terminates or on the incapacitation or death of your therapist, it will become necessary for another therapist to take possession of your counseling files. By signing this consent form, you give your consent to allowing a licensed mental health professional selected by your therapist to take possession of your file and records and provide you with copies upon request or to deliver them to a therapist of your choice.
Confidentiality-Initial ________________
Discussions between a therapist and a client are confidential. No information will be released without the client’s written consent unless mandated by law. It is the goal of the therapist to protect the confidentiality of your records; however, there are exceptions to confidentiality when limited according to legal requirements or specific consent.
Exceptions to Confidentiality- Exceptions to confidentiality are prescribed by the Licensing board in the State of Texas and include, but are not limited to, the following situations: 1) abuse or neglect of minors; abuse, neglect, or exploitation of the elderly; 2) a therapist’s duty to warn due to danger, physically or emotionally to the client, therapist or another person; 3) a subpoena or court order; 4) fee disputes between the therapist and the client; or 5) the filing of a complaint with the licensing board. Sessions may be recorded with proper notice to you. Please take note you are welcome to email or text me, however neither are considered confidential and I cannot completely safeguard your confidentiality.
Emergencies
Emergencies are urgent issues requiring immediate action. If there is a life-threatening emergency, go to the Emergency Room or call 911. I can be reached by calling 972-523-1235 and will respond as quickly as possible.
Payment for Services-Initial ________________
Payment is expected at the time services are rendered, after each session. The session fee for an individual is $125. Couples or family counseling is $160 per session. I accept cash, checks and all credit cards, including most health savings account cards. Fees incurred for returned checks are the client’s full responsibility. Fees for testing/assessments are separate from, and in additional to session fees. Please be advised I do not participate in person, by phone or in writing in any court related matter that the client may be a party to or become a party to in any way. I also do not write letters regarding your treatment to any entity, including court. Standard fees are subject to change with a 30 day notice.
Cancellations- Appointments canceled with 24 hour notice incur no fees and every effort will be made to reschedule in a timely manner. If you are unable to keep a scheduled appointment, please contact the office at 972-523-1235 at least 24 hours in advance.
Missed Appointments- Please be aware and understand that failure to call 24 hours in advance for cancellation of an appointment will result in you being billed $100 for that appointment. Call 972-523-1235. It is understood that emergencies and health problems do come up and I consider those when adequate notice is not given. However, no-shows/no call, and optional choices generally will not be considered. Your scheduled appointment has been set for you only; please be considerate of others who may need help as well. If an appointment is missed without prior notice you will be contacted; if you do not respond within 10 business days following the missed appointment, then it will be understood your therapy will have terminated.
Michael Dawson, MA, LPC
Christian and Traditional Counseling
www.fullylivingnow.com
1190 Parker Square, Flower Mound, TX 75028
972-523-1235
Fully Living
Living
ully Living
Living
Couples Counseling- I incorporate a number of different training and therapies with couples. However, my main focus is in the Gottman Method of Couples Therapy. While I have taken training in the Gottman Method Couples Therapy, please note I am completely independent in providing you with clinical services and I alone am fully responsible for those services. The Gottman Institute or its agents have no responsibility for the services you receive.
Individual sessions in the course of couples counseling is often necessary. Individual sessions are considered confidential unless a release has been signed. However, ‘secrets’ between couples detract from the therapeutic process and are discouraged. If issues are disclosed that are detrimental to the couple therapy, your therapist will discuss these with the individual and determine a course of action which could mean, in some instances, termination of the couple therapy.
Consent to Treatment
I voluntary agree to receive counseling services from Michael Dawson MA, LPC and authorize him to provide such care, treatment or services, as are considered necessary and advisable.
By signing this Client Information and Consent form, I acknowledge that I have both carefully read and understand all the terms and information contained herein. I have asked and sought clarification on any unclear terms or concepts at this time. I also acknowledge that I agree to all of the terms in this form and have received a copy.
Client(s) Date
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Therapist
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