Healthcare Art Therapy Form

HEALTHCARE ART THERAPY INFORMED CONSENT AND INTAKE FORM

Patient Information

Date of Birth:    Gender:    Preferred Pronouns:

Insurance Information

Clinical & Medical History

Presenting Concerns & Goals

Art Therapy: Description, Risks, Benefits

Art therapy combines therapeutic dialogue with creative processes using art materials. The clinician may use drawing, painting, collage, sculpture and other media to support assessment, emotional expression, coping skill development, problem solving, and symptom management. Sessions will be conducted by a credentialed clinician or supervised trainee.

Potential benefits: increased self-awareness, improved emotional regulation, development of adaptive coping strategies, and reduction of distress. Possible risks: emotional discomfort, temporary increase in distress, unexpected memories or feelings, or allergic reaction to materials. If a specific material causes irritation, inform the clinician immediately.

Participation is voluntary. The patient has the right to refuse any art activity, to stop a session at any time, and to withdraw consent for treatment. Requests to discontinue or modify activities will be respected within clinically appropriate limits.

I consent to participate in art therapy and related clinical activities under the clinician's direction.

I authorize photographing or scanning of my artwork for clinical records or supervision, provided identifying information is removed.

I authorize photographs or reproductions of my artwork that may include my name or identifying information for educational or public display (consent may be revoked in writing).

I authorize sharing of clinical information and artwork with the following persons/agencies:

Confidentiality and Limits

All clinical records and artwork are confidential and are part of the medical record. Exceptions to confidentiality are limited and include:

• Reasonable suspicion of child, elder, or dependent adult abuse or neglect;
• An imminent risk of serious harm to self or others;
• A valid court order or subpoena requiring release of records;
• Mandatory reporting obligations under applicable law;
• Communication required for billing and insurance claims.

Artwork placed in the clinical record may be retained, reproduced, or destroyed according to standard record-retention policies. Requests for release of records or artwork must be made in writing and will be processed in accordance with applicable legal and ethical requirements.

Authorization & HIPAA Acknowledgment

By signing below, I authorize art therapy services as described herein and authorize disclosure of protected health information for treatment, payment, and healthcare operations as necessary. I understand that I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on it.

I acknowledge receipt of the provider's Notice of Privacy Practices and understand my rights regarding my protected health information. I understand that if I have questions about privacy practices, I may contact the clinician or designated privacy officer.

I understand that participation in art therapy may require use of materials that leave residues on clothing or skin. I will inform the clinician of any material sensitivities or skin conditions prior to participating.

Additional Authorizations & Notices

Yes    No

Certification and Consent

I certify that the information I have provided on this form is accurate to the best of my knowledge. I have had the opportunity to ask questions about the nature, purpose, risks, benefits, and alternatives to art therapy and have received satisfactory answers. I understand that I may withdraw consent at any time in writing and that withdrawal will not affect prior disclosures made in reliance on this authorization.

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