Healthcare Behavioral Health Agreement

HEALTHCARE BEHAVIORAL HEALTH AGREEMENT

Parties and Effective Date

Patient Name:

Date of Birth:    Provider Name:

Agreement Effective Date:

Patient Information

Insurance Information

Medical and Behavioral Health History

Scope of Services and Goals

Description of Services: The provider will deliver behavioral health services which may include assessment, psychotherapy, medication management, care coordination, and crisis intervention as clinically indicated. Services are provided in accordance with professional standards of care and applicable law.

Session, Fees, and Billing

Frequency and Length of Sessions: Typical appointment length is and frequency is .

Fee for Service: Standard fee for services rendered is per session unless otherwise agreed in writing. Patient is responsible for co-payments, deductibles, and non-covered services.

Cancellation and No-Show Policy: Appointments canceled with less than notice may be subject to a charge of . Insurance may not reimburse for missed or late-cancelled appointments.

Confidentiality and Limits

Confidentiality: Information disclosed during treatment is confidential and will not be released without written authorization from the patient, except as required by law. Exceptions include, but are not limited to:

• Reasonable suspicion of child abuse or dependent adult/elder abuse;
• Imminent risk of serious harm to self or others (duty to warn and protect);
• Court order or other legal process requiring disclosure;
• Information necessary for billing and health care operations when using insurance.

The provider will make reasonable efforts to discuss disclosure with the patient prior to release when feasible. Disclosure will be limited to relevant information for the purpose identified.

Consent for Treatment and Telehealth

I consent to receiving behavioral health services from the provider named above, including psychotherapy and, when indicated, psychotropic medication management. I acknowledge that no guarantees of outcome have been made and that I may withdraw consent at any time in writing.

Telehealth (remote services): I consent to receive services via secure telehealth platforms when in-person care is not available or as clinically appropriate.

I consent to telehealth services.

Risks and benefits of telehealth have been explained, including limits of confidentiality, potential technical failures, and alternatives to remote care.

Coordination of Care and Release of Information

I authorize the provider to communicate with other health professionals, schools, or designated individuals for purposes of coordination of care, treatment planning, and continuity of services as necessary and permitted by law.

I authorize limited release of information for appointment scheduling and care coordination to the person named above.

Emergencies and Crisis Procedures

In the event of an emergency or imminent risk of harm, the provider will take steps to ensure safety, which may include contacting emergency services, designated emergency contacts, or arranging hospitalization. Patient agrees to provide accurate emergency contact information and to notify provider of any changes.

Termination of Services

Either party may terminate treatment at any time. Provider may terminate the therapeutic relationship for noncompliance, missed appointments, or behavior that jeopardizes safety, with reasonable notice and provision for urgent referrals when feasible.

Acknowledgment and HIPAA Authorization

I acknowledge that I have received and reviewed the provider's Notice of Privacy Practices describing my rights under the Health Insurance Portability and Accountability Act (HIPAA). I understand how my health information may be used and under what circumstances it may be disclosed.

I acknowledge receipt of the Notice of Privacy Practices.

Authorization Expiration: This authorization to use and disclose protected health information is valid until unless revoked earlier in writing.

Patient Rights and Certifications

I understand that I have the right to: ask questions about my care, refuse treatment (subject to clinical and legal limits), request amendment of my health records, and withdraw consent in writing. I certify that the information I have provided is accurate to the best of my knowledge.

Patient Initials:

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