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Mental Health Client Rights Statement

Mary Hayes Grieco, Spiritual Counselor
2100 1st Av. So.
Minneapolis, Mn. 55407
612-874-6622

Mary has a Bachelor of Arts degree with a background in psychology, and her spiritual self- training is eclectic, including intensive yoga studies since 1987. Mary was certified by Psychosynthesis International to facilitate the process of Unconditional Love and Forgiveness. She is the author of The Kitchen Mystic: Spiritual Lessons in Everyday Life.

THE STATE OF MINNESOTA HAS NOT ADOPTED UNIFORM EDUCATIONAL AND TRAINING STANDARDS FOR ALL MENTAL HEALTH PRACTITIONERS. THIS STATEMENT OF CREDENTIALS IS FOR INFORMATION PURPOSES ONLY.

If for some reason you need to file a complaint about this unlicensed mental health practitioner, you may contact the Office of Mental Health Practice, Mn. Dept. of Health PO Box 64975 St. Paul, Mn. 55164. 1 800 657-3957 

Client Counseling Agreement

I understand that Mary Hayes-Grieco is a counselor who works from a non-denominational spiritual framework that she has evolved out of her own spiritual experiences, and from a synthesis of traditional and non-traditional sources. I understand that she is not a psychologist or psychotherapist. I understand that I have a right to complete and current information regarding Mary’s assessment and recommended course of treatment, and the expected duration of treatment. I understand that I am free to seek any other services I choose while I am working with Mary, and that if she perceives that I have challenges that go beyond the scope of her experience she will refer me to appropriate resources, and that she will help me co-ordinate the transfer with my other caregivers. I know that I am entitled to courteous and respectful treatment free from verbal, physical, or sexual abuse from any caregiver, and that my sessions with Mary are confidential. All records and transactions of my work with Mary are confidential unless I authorize their release, and are available to me at any time, in accordance with Minnesota Statutes section 144.335 . I understand that I have the right to refuse services or treatment, unless otherwise provided by law, and that I may assert my rights without retaliation from the practitioner. 

I consider myself capable of using Mary's guidance in a mature way, that is "I will take what's good for me, and leave the rest." 

I acknowledge that I am responsible for my own growth, my own decisions, my actions and their consequences.

Payment Agreement

Payment is due on the day of services, in cash or by check. Mary does not take insurance. Mary’s fee is $125/hr for in person counseling and $140/hr for telephone counseling; You will be notified in a reasonable amount of time in advance of changes in services or charges.

Cancellation Policy

There is no cancellation charge for sudden illness or emergencies. Mary requests 48 hour notice for rescheduling your appointment if possible. If you cancel in less than 24 hours of your scheduled time, you are responsible to pay for the missed session.

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Client Information Form
First Name
Middle Name
Last Name
Street Address
City
State
Email Address
Home Phone
Work Phone
Date of Birth
Are you currently or have you ever been in ongoing counseling or psychotherapy? 
Yes   No
Are you currently under the care of a psychiatrist or taking any psychiatric medications?
Yes   No
Are you aware of any dysfunctional patterns in the family you have come from?
Alcoholism
Abuse - Physical
Abuse - Sexual
Abuse - Emotional
Workaholism
Food Disorders
Physical Neglect
Emotional Neglect
Mental Illness
Sex Addiction
Other
Are you struggling with any addictive behaviors at this time?
Yes   No
What kind of religious background (if any) do you have? 
Any ethnic influences?
Do you practice spirituality in any specific manner at this time?
Yes   No

Clicking 'Submit Client Information' button 

  1. Acknowledges you have read 'Client Rights Statement' and 

  2. Serves as your signed signature.

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