Healthcare Counseling Agreement

HEALTHCARE COUNSELING AGREEMENT

This Healthcare Counseling Agreement ("Agreement") is entered into by Provider Name: and Client Name: Effective Date:

Client Information

Emergency Contact

Insurance Information

Presenting Concerns and Treatment Goals

Medical & Mental Health History

Substance Use: Yes No

Current thoughts of self-harm or suicide: Yes No

Scope of Services

Provider will deliver behavioral health counseling, which may include assessment, individual therapy, couples or family therapy, care coordination, and case consultation as clinically indicated. Services may include evidence-based psychotherapeutic techniques and brief medication management coordination where applicable. Client consents to receive services under these terms and understands that no guarantee of outcomes is provided.

Delivery Mode: In-person Telehealth (video or phone) Group Family/Couples

Telehealth Consent: I consent to telehealth services and acknowledge the limitations, risks and benefits of telehealth including privacy risks and technology failures. I understand I may refuse telehealth and request in-person services where available.
Client provides consent for telehealth services

Fees, Payment & Cancellation

Standard Session Fee: $ per session unless otherwise agreed in writing.

Cancellation & No-Show Policy: Client agrees to provide at least 24 hours' notice for cancellation. Late cancellations or no-shows may be charged up to the full session fee unless waived for emergency circumstances.

Insurance Billing Authorization: I authorize Provider to submit claims to my insurance and to release clinical information necessary for billing and claims adjudication. I understand I am financially responsible for charges not covered by insurance.
Client authorizes billing to insurance

Confidentiality and Limits

Communications between Client and Provider are confidential and protected by law, with the following legally required exceptions where disclosure may occur without client consent: (1) suspected child abuse or dependent adult/elder abuse; (2) reasonable suspicion of imminent risk of serious harm to self or others; (3) disclosure ordered by a court of competent jurisdiction; (4) when records are necessary for billing and coordination with payers as authorized above. Provider may consult with clinical supervisors or legal counsel; identifying information will be disclosed only as required.

If the Client requests that records be released to a third party, a separate written authorization will be required specifying the recipient, purpose, and expiration. Authorization may be revoked in writing except to the extent information has been released in reliance on the authorization.

Electronic Communication

Client acknowledges the risks of unencrypted electronic communications (email, text messaging) including possible interception. Provider will use reasonable safeguards, but confidentiality cannot be absolutely guaranteed. Client consents to communication via:
Email SMS / Text Phone

Termination of Services

Either party may terminate services at any time. Provider may terminate services if client fails to comply with treatment recommendations, misses scheduled appointments without notice, or for administrative or safety reasons. Provider will make reasonable efforts to provide referrals or a plan for transition.

Authorization to Release Records (Optional)

Acknowledgment and Consent

By signing below, Client acknowledges that they have read and understand this Agreement, have had the opportunity to ask questions, consent to the treatment described, authorize Provider to deliver services and bill insurance as permitted above, and understand the limits of confidentiality described herein.

Client acknowledges receipt of Provider's privacy practices and notification of mandatory reporting obligations.

Provider Contact Information

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