M.Div, Ph.D.

​Licensed Clinical Professional Pastoral Counseling

Dr. Bosworth's Pastoral Counseling Agreement


I have read and understand the following pages of this website:​​

Fort Worth, Texas

Call Us:  (859) 475-4475

The two forms you will need before your first appointment are at the bottom of this page.  Please read the following BEFORE you read and complete the forms.  Thanks!

Robert W. Bosworth, Jr.,

Dr. Bosworth's Pastoral Counseling Agreement

I have read and understand the following pages of this website:


  • Counseling appointments are usually scheduled  for forty-five through fifty minutes.
  • Client and Counselor are to arrive on time and prepared for each session, including having all homework completed.
  • Clients will be billed for $25 if he/they miss an appointment without providing 24 hour's notice to the counselor.
  • The counselor may adjust the above fee at his discretion in case of emergency.
  • ​The counselor will cancel/reschedule sessions only when absolutely necessary, giving the client a reason for so doing.
  • Client and Counselor will silence all electronic devices and will not answer them during sessions.
  • Children under the age of fourteen will not be left unsupervised in the building during counseling sessions.
  • Dr. Bosworth does not provide child-sitting services.
  • Client will not hold counselor or hosting building responsible for any damage done to cars driven to sessions.
  • Client will provide the counselor with what he/they would like addressed/worked on in any particular session.
  • Client agrees to inform the counselor in writing of any changes in contact information and/or medication.
  • Client/Counselor relationships work best when the client does not engage other counselors to discuss the same subjects.
  • Counselor will give  client(s) an explanation in writing why the counselor/client relationship is to be terminated.
  • The counselor and client(s) will agree on a fee before or during the first counseling session.


With respect to client/counselor confidentiality, I understand the following statements.


  • Counselor will keep confidential what is told privately in counseling sessions. 
  • All client information will be kept in locked files for client privacy and security. 
  • HIPPA guidelines will be followed; clients will receive a handout with respect to these guidelines.  
  • Confidential information will not be released to anyone without the client's written consent. 
  • Information with respect to Child Abuse will be reported in accordance with State Law KRS 630.020 
  • KRS 209A.030 mandates the same for reporting adult abuse, which includes spouse abuse.
  • KRS 202A.400 mandates counselors to warn intended victims of client's threats of violence.
  • When a counselor judges a client to be at immediate risk for suicide and/or in need of emergency hospitalization,...........confidentiality is waived for the protection of the client.


Click Here  to download the New Client Letter.  READ THIS FIRST, before the following form.
Click Here to download a copy of the Application for Counseling which  must be complete before or at the first session.