Healthcare Counseling Client Packet

Healthcare Counseling Client Packet

Client Information

Date of Birth:    Gender: Female Male Non-binary/Other

Emergency Contact

Insurance Information

Medical & Mental Health History

Have you previously received mental health counseling? Yes No If yes, clinician and dates:

Presenting Concerns

Consent for Treatment & Counseling Agreement

I, the undersigned, voluntarily consent to participate in counseling services provided by the clinician or authorized staff. I understand that counseling involves discussing personal information and that there are no guarantees of specific results. I understand the nature of common therapeutic methods that may be used and that treatment plans will be discussed and documented in my clinical record.

I understand that I may withdraw consent at any time, and that termination of services does not relieve me of any financial obligations incurred. I acknowledge that the clinician will discuss anticipated frequency and estimated duration of services and will provide information about alternatives and potential risks and benefits.

Limits of Confidentiality

Except as described below, information disclosed in counseling is confidential. Exceptions to confidentiality include: (1) suspected abuse or neglect of a child, elder, or dependent adult which by law must be reported; (2) a reasonable suspicion that the client presents a serious danger of harm to self or others, including threats of violence; (3) if a court orders disclosure; (4) when records are subpoenaed; (5) instances of fraud or if consultation with other clinicians is necessary for clinical care. When possible, the clinician will inform the client before a disclosure is made.

HIPAA Authorization and Release of Information

I authorize the release of my protected health information to the individuals or entities named below for the purpose of treatment, billing, coordination of care, or as otherwise indicated.

All clinical records
Treatment summary
Billing and insurance information
Medical history and medication lists

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. This authorization is voluntary and not a condition of receiving treatment unless noted otherwise for specific administrative purposes.

Telehealth / Remote Services Consent

I consent to participate in telehealth sessions when offered or agreed upon. I understand the benefits and risks of telehealth, including potential technology failures, reduced nonverbal cues, and risks to confidentiality inherent in electronic communication. I agree to a private location and secure connection for sessions.

I consent to telehealth: Yes No

Fees, Cancellation & Payment

Standard session fee: $ . Unless otherwise arranged, payment is due at time of service. Insurance billing will be submitted only with signed authorization above. Cancellation must be provided at least 24 hours in advance; late cancellations or missed appointments may incur the full session fee.

I agree to provide accurate insurance information and understand that I am responsible for fees not covered by insurance, co-payments, deductibles, and any costs incurred for collections.

Client Rights & Complaints

I understand my rights include respectful care, informed consent, the right to refuse services, and the right to request amendment of my records. Complaints about services may be made in writing to the practice administration; a record of the complaint and its resolution will be maintained.

Additional Authorizations / Notes

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