Healthcare Counseling Center

Healthcare Counseling Center — Client Intake & Consent

Patient Information

Date of Birth:    Gender: Male Female Other/Prefer not to say

Emergency Contact & Primary Care

Insurance / Billing Information

Medical & Mental Health History

Are you currently experiencing thoughts of harming yourself or others? Self-harm Harm to others

Consent for Counseling Services

I, the undersigned, authorize licensed clinicians and supervised trainees at Healthcare Counseling Center to provide psychological and counseling services. Counseling may include assessment, diagnosis, individual and/or family therapy, and referral. I understand that treatment is voluntary and I may withdraw consent at any time by providing written notice, except where otherwise permitted by law.

I acknowledge that counseling has benefits and risks. Benefits may include symptom reduction and improved coping; risks may include emotional discomfort. No guarantee is made regarding specific outcomes.

Consent to receive services: I consent to outpatient behavioral health services at Healthcare Counseling Center.

Telehealth Consent (if requested)

Telehealth involves the delivery of services using interactive audio and video. I understand there are potential risks, including technology failures and reduced privacy. I have the right to refuse telehealth and request in-person services when available.

Consent to telehealth: I consent to receive services via telehealth when clinically appropriate.

Limits of Confidentiality & Mandatory Reporting

Except as required or permitted by law, information disclosed in counseling is confidential and will not be released without my written authorization. Exceptions include: (1) imminent risk of harm to self or others; (2) suspected abuse or neglect of a child, dependent adult, or elder; (3) court order or subpoena; (4) when I sign a separate release of information. Clinicians may also consult with supervisors and professional colleagues; such consultations maintain client confidentiality to the greatest extent possible.

Release for Emergency Contact & Coordination of Care

I authorize the clinician to contact the named emergency contact and/or my primary care provider if the clinician determines it is necessary to address a serious risk to my health or safety or to coordinate care.

Release for coordination: Authorize communication with emergency contacts, medical providers, and insurance for purposes of treatment and safety.

HIPAA Authorization & Privacy Acknowledgment

I acknowledge that I have been offered or received the practice's Notice of Privacy Practices which describes how my protected health information (PHI) may be used and disclosed and how I can obtain access to this information. I understand my rights under applicable privacy laws.

HIPAA acknowledgement: I acknowledge receipt of the privacy practices notice.

Authorization to Release Information (Optional)

Expiration: This authorization will expire on unless earlier revoked in writing.

Financial Responsibility & Cancellation

I understand that I am financially responsible for fees not covered by insurance, including co-payments and deductibles. Payment is due at the time of service unless other arrangements have been made. I agree to pay late or missed appointment fees in accordance with the practice policy.

Additional Notices & Certifications

By signing below I certify that the information I have provided is true and complete to the best of my knowledge. I authorize release of information to process insurance claims as necessary. I understand that I may revoke authorizations in writing except to the extent action has already been taken in reliance on them.

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