Healthcare Counseling Solutions Template

Healthcare Counseling Solutions Template

Provider Information

Patient Information

Emergency Contact

Insurance Information

Medical & Mental Health History

Presenting Concerns & Screening

Symptom Checklist — check all that apply:
Depression Anxiety Panic Attacks Substance Use Sleep Problems Eating Concerns Relationship Issues Other

Current suicidal ideation or intent? Yes No

Current homicidal ideation or intent? Yes No

Consent for Treatment

I, Patient Name: , voluntarily consent to receive mental health counseling services from Healthcare Counseling Solutions or its clinicians. I understand counseling involves assessment, interventions, and may include homework or referrals. Counseling is not a guarantee of specific outcomes.

I acknowledge that I may withdraw consent at any time by providing written notice to the clinician. Withdrawal of consent will not affect actions taken by the clinician prior to receipt of such notice.

Limits to confidentiality: The clinician will keep information confidential except where disclosure is required or permitted by law, including imminent risk of harm to self or others, suspected abuse or neglect of a minor, dependent, or elderly person, or by court order. In such cases, relevant information will be disclosed to appropriate authorities or third parties as required.

Authorization to Bill and Release Information

I authorize Healthcare Counseling Solutions to bill my insurance and to furnish to my insurer such information from my clinical record as is necessary for claims processing. I understand that if I do not provide complete insurance information or if services are not covered, I am responsible for payment.

I authorize release of my protected health information to:

Purpose of disclosure:

This authorization will expire on: unless revoked earlier in writing.

Telehealth Consent

Telehealth involves the delivery of behavioral health services using interactive audio, video, or electronic communications. There are risks including interruptions, technical failures, and privacy limitations. By checking below I consent to receive telehealth services when clinically appropriate.

I consent to telehealth services and understand the associated risks and benefits.

Fees, Payment, and Cancellation

Fees for services will be discussed and agreed upon with the clinician. If applicable, co-pays are due at time of service. Cancellation policy: appointments cancelled with less than 24 hours notice may incur a charge. Balances unpaid after 60 days may result in suspension of services or referral to collections.

I have read and understand the fees and cancellation policy.

Patient Rights & Acknowledgement

I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices describing how my protected health information may be used and disclosed and my rights under applicable privacy laws.

I acknowledge receipt of the privacy notice.

Consent Certification

By signing below I certify that the information I have provided is true and correct to the best of my knowledge and that I have read, understand, and agree to the provisions of this form. I authorize treatment and the release of information as described above.

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