Healthcare Counseling Paperwork

HEALTHCARE COUNSELING PAPERWORK

Patient Information

Client Name:

Date of Birth:   Gender: Male Female Non-binary Prefer not to say

Emergency Contact

Insurance Information

Medical & Mental Health History

Have you had thoughts of harming yourself or others in the past year? Yes No

Consent for Counseling Services

I hereby consent to participate in counseling and related services provided by the counselor or clinical staff. Counseling may include assessment, individual psychotherapy, group therapy, family therapy, and crisis intervention. Expected benefits include improved coping, symptom reduction, and enhanced functioning. Risks may include emotional discomfort, disruption in relationships, or the emergence of difficult memories.

Alternatives to counseling include referral to medical providers, psychiatric consultation, or community supports. I understand I may withdraw consent at any time, subject to clinician obligations to provide necessary referrals or emergency interventions.

I consent to receive telehealth/remote services when clinically appropriate. I consent

Confidentiality and Limits

Counselor-client communications are confidential and protected by law, except in specific circumstances where disclosure is required or permitted: (1) imminent risk of serious harm to self or others; (2) suspected child, elder, or dependent adult abuse or neglect; (3) court order or mandatory reporting; (4) information necessary for billing or collection; or (5) when the client provides written authorization for release. Counselors may consult with clinical supervisors and legal counsel; such consultations will protect identifying information to the extent possible.

HIPAA / Communications

I acknowledge that the practice maintains a Notice of Privacy Practices describing how my protected health information may be used and disclosed. I authorize the practice to use and disclose protected health information for treatment, payment, and healthcare operations as necessary.

Permission to leave confidential messages for appointment reminders or clinical matters: Voicemail at primary phone Email Text message

I acknowledge receipt of the Notice of Privacy Practices: Acknowledged

Release of Information (Optional)

I authorize the release of my behavioral health information to the following recipient for the stated purpose:

Information to be released: Treatment summary Progress notes Billing records All records

This authorization expires on:   I understand I may revoke this authorization in writing at any time except to the extent action has already been taken in reliance on it.

Financial Agreement

I agree to be financially responsible for services rendered. Insurance billing will be submitted as a courtesy where permitted. I authorize my insurance benefits be paid directly to the provider when applicable and assign benefits for claims related to counseling services.

Cancellation policy: I understand that missed appointments or cancellations with less than 24 hours' notice may incur a fee. I accept responsibility for charges not covered by insurance. I acknowledge

Consent & Certification

By signing this document I certify that the information I have provided is accurate to the best of my knowledge. I authorize the counselor and staff to provide treatment and to exchange information for the purposes described above. I understand my rights and the limits of confidentiality as stated in this form.

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