Consent to Treatment and Confidentiality Forms

Please read:

Hippa Notice of Privacy

Please Read and Sign

Consent to Treatment

This is a 10 Page document and will take some time to read and fill out. You can do so in Adobe or google docs.

3rd party consent:

Release of Information 


*Although she holds a Masters in Counseling, Rebekah is not a clinical counselor or psychotherapist. She is a Spiritual Adviser who adheres to ACA ethical guidelines and provides her services as a Breakup Specialist under the “Coaching” umbrella.