Counseling Intake Disclosures

COUNSELING INTAKE DISCLOSURES

Client Name:    Date of Birth: / /

Client Information

Services and Scope

Nature of services to be provided and presenting concerns. The following describes the intended scope of counseling services, typical methods used, and mutually agreed goals. Services do not include legal, forensic, or emergency services unless otherwise agreed in writing.

Payment Terms

Fees, billing, and payment obligations. Client is responsible for payment regardless of insurance benefits. Where a fee schedule applies, it is set out below.

Term and Termination

Commencement and termination of services, and required notice to terminate the counseling relationship.

Start Date: / /    Anticipated End Date (if any): / /

Either party may terminate services upon the provision of the required notice. The practitioner may terminate immediately when there is a professional concern for client safety, nonpayment, or when continuation would violate professional obligations.

Confidentiality and Limits

Communications between client and counselor are confidential and will not be disclosed without written consent except as required or permitted by law. Limitations and exceptions include, but are not limited to:

• Reasonable belief of imminent risk of harm to self or others (duty to warn/protect);
• Reasonable suspicion of abuse or neglect of minors, elders, or dependent adults;
• Subpoena or court order directing disclosure;
• Claims involving professional liability or malpractice;
• Billing and insurance claims where client has authorized submission of information to a third-party payer.

Records are maintained for clinical, billing, and legal purposes. Summaries of treatment may be released only with written authorization except where otherwise required by law.

Telehealth, Electronic Communication and Recording

Telehealth sessions are offered when appropriate. Client consents to or declines remote services by selecting below. Electronic communications (email, text) carry security risks and should not be used for urgent matters.

I consent to telehealth services and acknowledge the risks described above.
I consent to electronic communications for scheduling and non-sensitive administrative matters and accept associated privacy risks.
I acknowledge that audio or video recording of sessions is prohibited without advance written consent.

Insurance, Billing, and Release

If the client requests that services be submitted to a health plan or other third party for reimbursement, client authorizes the counselor to provide necessary clinical information for claims processing. Client remains responsible for payment of all charges.

I authorize billing to my insurance/third-party payer as necessary for claims processing.
I understand and accept ultimate financial responsibility for fees not covered or reimbursed by any third-party payer.

Cancellation and No-Show Policy

Appointments cancelled less than the required notice period may be subject to a cancellation fee as set below. Repeated late cancellations or no-shows may result in termination of services.

Recordkeeping and Access

The counselor maintains clinical records which may include session notes, treatment plans, and billing records. Client may request access to records; requests will be handled in accordance with professional and legal standards.

Acknowledgment and Consent

By signing below, I acknowledge that I have read and understand these disclosures, that I have had an opportunity to ask questions, and that I consent to the provision of counseling services under the terms stated. I understand my rights and the limits of confidentiality described herein.

Entire Agreement: These disclosures and any signed service agreement constitute the entire understanding between the parties with respect to counseling services and supersede prior oral or written communications. Amendments must be in writing and signed by both parties.

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