Healthcare Family Counseling Form

HEALTHCARE FAMILY COUNSELING FORM

Client / Primary Contact Information

Date of Birth:    Gender: Male Female Other

Emergency Contact

Family / Household Members to be Involved

List names and ages of family members who will participate in counseling.

Insurance and Billing

Presenting Concerns and Goals

Please describe the primary concerns prompting you to seek family counseling, and list desired goals for therapy.

Medical & Mental Health History

History of suicidal ideation or self-harm: Yes No    History of violence or harm to others: Yes No

Consent for Family Counseling Services

I consent to receive family counseling services from the clinician and understand that treatment may include, but is not limited to, individual, couple, and family sessions, clinical assessment, treatment planning, interventions, and referrals where appropriate. I understand that participation by family members requires their informed consent and that confidentiality applies to information disclosed in session except as provided below.

Limits of confidentiality include: (1) suspected child, elder, or dependent adult abuse or neglect; (2) imminent risk of harm to self or others; (3) disclosures subject to a court order or valid subpoena; (4) information exchanged with other healthcare providers for coordination of care when necessary and authorized for billing. When family members participate, the clinician may need to share relevant clinical information among participants for treatment purposes.

I acknowledge that I have the right to withdraw consent for any specific family member's participation at any time, but that withdrawal does not negate information already documented in the clinical record.

By checking this box I give informed consent for family counseling services as described above.

HIPAA / Privacy Acknowledgment & Authorization

I acknowledge receipt of the practice's privacy practices and understand that my protected health information may be used for treatment, payment, and healthcare operations. I authorize the clinician and practice to use and disclose my health information to insurers, other treating providers, and billing agents to the extent necessary to process claims and coordinate care.

I authorize release of clinical information necessary for insurance billing and agree that a claim may contain clinical diagnosis, treatment dates, and treatment descriptions. I understand that insurance companies may require copies of clinical records and that I may be billed for records requested by third parties unless otherwise required by law.

By checking this box I acknowledge the privacy practices and authorize use and disclosure as described.

Telehealth / Remote Session Consent

I consent to the use of secure telehealth technology (video or telephone) for counseling when in-person sessions are not feasible. I understand differences in confidentiality risks with electronic communications and agree to follow clinician instructions to protect privacy during remote sessions.

By checking this box I consent to telehealth/remote sessions.

Fees, Payment, and Cancellation Policy

Fees for services, co-payments, and any balances not covered by insurance are the responsibility of the client or responsible party. Payment is due at the time of service unless other arrangements are agreed upon in writing. If insurance is billed, any amount not paid by the insurer becomes the client's responsibility.

Cancellations require at least 24 hours' notice. Late cancellations and missed appointments may be subject to a cancellation fee equal to the full session rate or as otherwise disclosed by the practice. Repeated missed appointments may result in termination of services.

By checking this box I acknowledge and accept the fee and cancellation policy.

Authorization for Emergency Contact / Release for Coordination of Care

I authorize the clinician to contact the emergency contact listed above, or other designated individuals, if there is concern for my safety or the safety of others, or if I am incapacitated. I authorize limited exchange of information with other healthcare providers to coordinate care as needed.

By checking this box I authorize emergency contact and coordination of care as described.

Voluntary Acknowledgment

I understand that participation in counseling services is voluntary. I have had an opportunity to ask questions about the services, risks, benefits, and alternatives. I understand I may discontinue treatment at any time and may request copies of my records in writing unless restricted by law.

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