Counseling Session Acknowledgement and Signature Form
Please complete this form to acknowledge your participation in the counseling session and provide your signature.
Participant Full Name
*
First Name
Last Name
Counselor Full Name
*
First Name
Last Name
Session Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Session Location
*
Session Type
*
Individual
Group
Family
Other
Participant Email Address
*
example@example.com
Best Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Comments or Feedback (optional)
Participant Signature
*
Submit
Submit
Should be Empty: