Healthcare Counseling Consent Form

Healthcare Counseling Consent Form

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Relationship:    Phone:

Insurance & Billing

Policy Number:    Group Number:

I authorize the practice to bill my insurance and to disclose necessary information for billing purposes:

Medical & Mental Health History

Counseling Services — Purpose & Scope

Estimated length of treatment:

Treatment modalities (check all that apply):  Telehealth   In-person   Group therapy

Risks, Benefits & Alternatives

Counseling may produce benefits such as symptom reduction, improved coping, and increased functioning. Counseling also carries potential risks including emotional discomfort, temporary increase in symptom intensity, or changes in personal relationships. Alternative options include medication management, different therapists, crisis services, or referral to higher level care where appropriate.

I have read and discussed these risks and benefits with my counselor and understand them:

Confidentiality & Limits

Communications between patient and counselor are confidential and protected by law. Exceptions to confidentiality include: (1) suspected abuse or neglect of a child, dependent adult, or elder; (2) reasonable belief of imminent risk of serious harm to self or others; (3) if records are subpoenaed by a court or required by law; (4) where disclosure is necessary to coordinate emergency medical or safety services. Billing statements may contain limited information necessary for claims processing.

I understand these limits and consent to counseling under these terms:

Telehealth & Electronic Communications

Telehealth involves counseling delivered through audio and/or video technology. Telehealth carries risks such as technology failure, confidentiality breaches, and limitations in observation. I understand alternatives to telehealth and that I may opt out without penalty.

I consent to receive counseling via telehealth when offered:

I consent to the use of secure electronic communications (email, text) for scheduling and brief communications, understanding that such methods may carry privacy risks:

Recording Sessions

Audio or video recording of sessions will occur only with explicit, written consent. Recordings, if any, will be stored securely and destroyed according to practice policy.

I consent to audio/video recording of sessions for clinical or supervisory purposes:   If yes, describe purpose:

Release of Information / Authorization

I authorize the counselor to release information to the party named below for the stated purpose. I understand I may revoke this authorization in writing except to the extent action has already been taken.

Authorization Expiration Date:

Patient Rights & Acknowledgements

I have the right to ask questions about my care, to receive information about alternatives, and to withdraw consent at any time. Withdrawal of consent must be submitted in writing and will not affect actions already taken in reliance on this consent.

I acknowledge receipt of the privacy practices and understand my rights under applicable privacy laws:

Consent and Certification

By signing below, I voluntarily consent to receive mental health counseling services from the identified provider. I certify that I have read and understand the information on this form, have had the opportunity to ask questions, and that my questions were answered to my satisfaction.

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