Healthcare Counseling Disclosure

HEALTHCARE COUNSELING DISCLOSURE

Client Identification

Client Name:    Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical & Mental Health History

Counseling: Scope, Goals, and Methods

Counseling services involve a collaborative process to address emotional, behavioral, and relational concerns. Interventions may include assessment, individual counseling, family therapy, brief crisis management, and referrals to other professionals when clinically indicated. The provider will formulate goals with the client and periodically review progress.

Confidentiality and Its Limits

Communications between client and counselor are confidential and will be maintained in clinical records. However, confidentiality is limited in the following circumstances: (1) reasonable belief of imminent harm to self; (2) reasonable belief of imminent harm to others; (3) reasonable suspicion of child abuse, elder abuse, or dependent adult abuse; (4) court order or subpoena; (5) when disclosure is necessary for treatment, payment, or health care operations and the client has signed an authorization for release; and (6) limited disclosures to supervisors or consultation with other professionals when necessary for quality care.

I acknowledge that I have read and understand the limits of confidentiality described above:

Risks, Benefits, and Voluntary Nature

Counseling carries potential benefits, including reduced distress and improved functioning. There are also foreseeable risks, including uncomfortable emotions, relationship changes, or negative reactions when confronting difficult material. Participation is voluntary. The client may withdraw consent and discontinue services at any time without penalty.

Telehealth and Electronic Communications

Telehealth sessions use synchronous audio and/or video technologies. Telehealth may present risks including technology failures, breaches of privacy, and limits to assessment. Electronic communications (email, text messaging) are not fully secure and may be used only with client consent for scheduling and brief communications. Emergency communications by electronic means cannot be guaranteed.

I consent to receive counseling via telehealth when clinically appropriate:

I consent to the use of email or text messaging for non-emergency communications:

Authorization for Use and Disclosure (if applicable)

Client authorizes release of protected health information for treatment, payment, and healthcare operations as needed. For disclosures beyond treatment and payment, client authorization is required. This authorization is valid until:

Fees, Billing, and Cancellation

Insurance billing may require disclosure of limited clinical information to the insurer. Client authorizes submission of claims and understands financial responsibility for services not covered by insurance.

Emergencies and After-Hours

The counselor does not provide 24-hour crisis services. For emergencies or imminent risk of harm, contact local emergency services or proceed to the nearest emergency facility. The counselor will provide crisis resources and make reasonable attempts to respond to urgent messages during regular business hours.

Minors and Guardianship

For clients under 18, a parent or legal guardian may have the right to access portions of the clinical record. When appropriate, information may be shared with parents to promote the minor's care. Consent by a guardian is required for treatment of minors, except as allowed by law.

HIPAA / Privacy Practices Acknowledgment

I acknowledge that I have been offered or received a copy of the provider's Notice of Privacy Practices describing how protected health information may be used and disclosed and how I can access this information.

Consent and Authorization

By signing below, I voluntarily consent to receive counseling services. I understand the information provided in this disclosure, including limits of confidentiality, risks and benefits, fees, and policies. I authorize the counselor to provide treatment, maintain records, and, where authorized, release information as necessary for care and billing. I understand I may withdraw consent in writing except where actions have already been taken in reliance on this consent.

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