We ask you to affirm that you are the person identified above and commit to personally completing this process.
I certify that all the information provided on this page and all future information I provide to Family Services, Inc. DBA Origin SC throughout my time as a client is true, correct, complete, and offered in good faith. I understand that it is my personal responsibility as a client of Origin SC to participate in and complete the counseling session. I also certify that I will complete this counseling session myself I understand that knowingly making a false or fraudulent statement, misrepresenting my identity or not participating in my counseling session is a violation of the requirements for obtaining a certificate and may result in its revocation as well as the termination of my privileges as an Origin SC client.
By entering my initials below, I affirm my identity and my understanding of the policies outlined above.
(Please estimate monthly figures.)