Healthcare Counseling Packet

Healthcare Counseling Packet

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Subscriber Date of Birth:

Medical & Mental Health History

Primary Care Physician:    Phone:

Mental Health Specifics

Have you received prior counseling or psychotherapy?   Yes    No

History of self-harm or suicide attempts?   Yes    No

Depression    Anxiety    Panic Attacks    Trauma/PTSD    OCD    Other

Consent for Counseling Services

I authorize and consent to receive mental health assessment and counseling services from the provider named on file. Counseling is a collaborative process that may involve discussion of personal issues, emotional distress, and life history. Expected benefits include symptom reduction, improved coping skills, and increased well-being. Risks may include experiencing uncomfortable emotions, remembering painful events, or temporary increases in distress.

I understand that I may withdraw consent at any time except where action has already been taken on the basis of this consent. I understand the counselor may consult with clinical supervisors or colleagues without revealing identifying details when necessary for quality of care.

Limits to confidentiality include: (1) disclosure required by statute for suspected abuse or neglect of a child, dependent adult, or elder; (2) imminent risk of serious harm to self or others; (3) court order or other legal process; and (4) mandatory reporting obligations. Communications may also be disclosed for collection of payment and clinical coordination with other health care providers as authorized below.

I have read and understand the above information and give my informed consent to receive counseling services.

I understand and consent to counseling as described above.

HIPAA Authorization & Release of Information

I acknowledge receipt of the provider's Notice of Privacy Practices describing how my protected health information (PHI) may be used and disclosed and my rights with respect to that information.

I authorize the release of relevant PHI for the purpose of coordination of care, treatment, billing, referral, and legal reporting as required. This authorization includes release of mental health records, treatment summaries, and medication information as reasonably necessary for the stated purpose.

Authorization Expiration Date:

I acknowledge receipt of the Notice of Privacy Practices and authorize release as specified above.

Telehealth Consent

I consent to receiving telehealth services (audio and/or video-based clinical services). I understand there are benefits and risks associated with telehealth, including technical failures, limitations in nonverbal communication, and reduced confidentiality on third-party platforms. I agree that the provider and I will use reasonable safeguards to protect privacy.

I consent to telehealth services as described above.

Billing and Payment Agreement

Fees for services, co-payments, and billing practices will be discussed at intake. I agree to pay for services not covered by my insurance and understand I remain responsible for amounts due. Cancellation policy: appointments cancelled with less than 24 hours' notice may incur a cancellation fee.

Acknowledgment & Certification

By signing below I certify that the information I have provided in this packet is true and accurate to the best of my knowledge. I understand that withholding information may compromise care. I authorize communication with my insurance carrier for billing and payment. I understand my rights regarding confidentiality and agree to the terms set forth in this packet.

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