Healthcare CSW Form

Healthcare CSW Form

Patient Information

Date of Birth:    Gender:

Primary Phone:    Secondary Phone:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy/ID Number:    Group Number:

Subscriber Date of Birth:

Medical & Mental Health History

History of mental health treatment? Yes No

History of substance use or dependence? Yes No

Consent for Services by Clinical Social Worker (CSW)

I hereby consent to assessment and clinical services provided by the Clinical Social Worker (CSW). The CSW is authorized to conduct psychosocial assessment, provide psychotherapy, case coordination, crisis intervention, and make referrals as clinically indicated. I understand that services are voluntary and that I may withdraw consent at any time by notifying the CSW in writing.

Potential benefits include symptom reduction, improved functioning, and enhanced coping skills. Risks may include temporary discomfort, emotional upset, changes in relationships, or the need to address difficult memories or feelings. No guarantees of specific outcomes are given.

I acknowledge that I have had the opportunity to discuss the nature, purpose, benefits, and risks of treatment, and that my questions have been answered. I understand the limits of confidentiality described below.

Confidentiality and Limits

Information disclosed during treatment is confidential and will not be released without my written authorization, except as required or permitted by law. Exceptions include: suspected abuse or neglect of a child, dependent adult, or elder; credible threat of serious harm to self or others; court order or legal process; and mandatory reporting by law. If such exceptions apply, the CSW will make reasonable efforts to inform me when permitted.

Authorization to Use and Disclose Health Information (HIPAA)

By checking the box below I authorize the CSW to use and disclose my protected health information for treatment, payment, and health care operations as necessary for coordination of care and billing, consistent with professional standards and applicable privacy laws.

I authorize use and disclosure as described above.

Release of Information

I authorize the CSW to release information to the following persons or agencies for care coordination and emergencies. I understand I may revoke this authorization in writing except to the extent action has already been taken.

Phone:    Relationship:

Phone:    Relationship:

Telehealth / Remote Services

I consent to receive clinical services via telehealth (audio/video) when recommended by the CSW. I understand the risks include, but are not limited to, technical interruptions, privacy limitations, and situations where telehealth may be insufficient to meet my needs. I may decline telehealth and request in-person services when available.

I consent to telehealth services.

Financial Responsibility & Cancellation

I agree to be responsible for co-payments, deductibles, and any fees not covered by insurance. Cancellation or missed appointment policies apply; I understand that late cancellations or no-shows may incur a fee as set by the practice. Billing and collection practices will comply with applicable law.

Acknowledgment & Certification

By signing below, I certify that the information provided on this form is accurate to the best of my knowledge. I consent to assessment and treatment by the Clinical Social Worker. I have read and understand the statements regarding confidentiality, HIPAA authorization, release of information, telehealth, and financial responsibility. I understand I may revoke authorizations in writing except to the extent that actions have already been taken in reliance on them.

Sign Now