We have provided our forms online, for your convenience. You may download, print, and fill out the following forms prior to your counseling visit. Each person will need to complete the Information Paperwork separately, but the disclosure is per couple/family:
New Client(s) Information Paperwork (for all counseling except Marriage Prep counseling)
DOWNLOAD: New Client Information Form
Marriage Prep Information Paperwork (specifically for Pre-marital/Marriage Prep counseling sessions)
DOWNLOAD: Marriage Prep Information Form
Our RCC Disclosure Form
Read our counseling disclosure ahead of time! In this document you will find information about us as counselors, and as a counseling agency.
We will talk through our disclosure with you at your initial session and you can sign it then. Bring your questions to the first session, and we’ll gladly answer them. If you wish, you may download the most current disclosure forms here.
DOWNLOAD General: RCC Confidentiality and Disclosure form
Good Faith Estimate Notice (for Private Pay)
“Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act
Starting on January 1, 2022, the No Surprises Act (NSA) requires that health care providers and facilities give uninsured (or self-pay) individuals an estimate for the cost of their health care before the individual agrees to the service. Since we are “private pay” for our co-therapy sessions and most of our individual sessions, we provide you with this information for your self-pay sessions. You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. We will provide you with a personalized version of a Good Faith Estimate when you become our client. See the PDF for more detailed information (can be downloaded and printed if desired). For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call us at 515-635-1805.
DOWNLOAD: Good Faith Estimate