Conflict Resolution Counseling Liability Release Form
Use this form to provide your details, describe the conflict, and acknowledge the counseling release before participating in a conflict resolution session.
Client Information
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Please Select
Email
Phone
Text Message
Organization or Relationship to Other Party (if applicable)
Conflict and Session Details
Conflict/Topic Description
*
Other Parties Involved
Preferred Session Format
Please Select
In-person
Virtual
Either
Other
Requested Session Date and Time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Immediate Safety Concerns or Boundaries
Liability Release and Acknowledgment
Client Signature and Date
*
Submit
Submit
Should be Empty: