Yazdi Bellihomji, NCCA Certified Temperament Counselor

Client Disclosure Statement and Fee Agreement

Yazdi Bellihomji is an independent certified Temperament counseling entity. Temperament counseling is offered to individuals seeking to integrate their faith into the process of resolving issues. Temperament Counseling is performed by staff not licensed by the state of NY or NJ, or CT as the states do not currently require that Temperament counselors be licensed. Licensure and certifications are obtained through the National Christian Counselors Association, and its affiliates, approved by the National Board of Clinical Christian Therapists.

The requirements of such certification include training in theology and counseling technique, including the utilization of the APS System, (Arno Profile System), Rational Emotive Behavioral Therapy, Nouthetic or Biblical counseling, and other techniques approved of by Safe Harbor Counseling.

The primary goal of Pastoral Counseling trough these services is to bring an individual to an intimate understanding of God’s Word, a relationship with Jesus Christ, and the gaining of ability to apply Biblical truths and principals to their every day lives, situations, and to effect healing of deep emotional issues that are causing problems in one’s life. All decisions made concerning actions taken by the client, are the sole responsibility of the client, as they have willingly chosen to submit themselves to counsel to aid their decision making process, not to have decisions made for them. Our belief is that a balanced healthy life is obtained through taking responsibility for our actions and dealing realistically with the consequences of our actions.

The amount of sessions necessary to effect such change obviously varies from case to case; however, we will endeavor to counsel an individual or couple for a period of 4 to 16 sessions, depending on response to therapy. Most people remain in therapy until they feel they have gained improved methods of thinking, feeling and acting regarding their difficulties. You are free to discontinue therapy at any time . Occasionally a therapist will decide to discontinue therapy for various reasons. In such a case, we will endeavor to refer you to a qualified therapist more able to meet your particular need.

Under normal circumstances, everything you discuss with your counselor will be held in strict confidence. However, you should be aware that there are certain situations in which your counselor may be required by law to report information to proper authorities without your permission or knowledge.

These situations may include bodily harm to self or others; involvement in a felony; suicidal intentions; evidence of child or elder abuse or neglect, or other abuse scenarios. Your counselor may also be required to provide information in response to a subpoena by a court of law.

A note regarding substance abuse issues and treatment: If you are struggling with substance abuse issues or other life controlling problems, we may suggest additional recovery, medical and/or psychological treatment options in addition to counseling. These options will be your choice to partake of and benefit from, however, the choice to not follow suggested methods of care, may preclude our ability to provide counseling in your particular situation.

Other counselors and/or professionals, including Registered Nurses, Psychiatrists, Psychologists and other health care providers and professionals, may be suggested as a part of your therapeutic care. The utilization of any of these suggested parties will be solely the responsibility of the client, and no liability to Safe Harbor Counseling, or any affiliated counselor or provider shall be held liable for any issues regarding the use of such parties.

Yazdi Bellihomji shall hold no liability for damages of any kind incurred as a result of counseling services provided. All life decisions are the sole responsibility of the party seeking counseling assistance.

Yazdi Bellihomji may suggest or incorporate other professional counselors in your plan of care. They are independent counselors, (or others, who’s role will be made known to you), and the decision to receive counsel from any such individual is the sole responsibility of the client.

Occasionally a student or other party may sit in during a counseling session. This will be for teaching students and/or for accountability purposes, or for the comfort of a particular counselee, ( ie. male/female situations).

FEE STRUCTURE AND AGREEMENT

Payment for services rendered are due at time of service unless otherwise agreed in advance. NO insurance is accepted for counseling services. A typical counseling session duration is 50 to 75 minutes. The fee for one individual counseling session is $95.00. If two counselors are present during a session, (as in marriage counseling), the fee will be $150 for that session.

If you feel you do not have the ability to be responsible for these fees, you are required to disclose such information PRIOR to entering into a counseling relationship with Safe Harbor Counseling Services. Please call within 24 hours if you are unable to keep your appointment.

If you do not call you will be required to pay a $25 fee prior to scheduling
another appointment.

Other arrangements may be agreed upon with discussion of financial arrangements.

There is a one-time fee to process the APS profile, integral to the counseling process
of $65 per profile.

I/We the undersigned, have fully discussed, understand, and agree upon, and will abide
by all above outlined policies.

FINANCIAL ARRANGEMENTS: