Healthcare Family Institute Form

HEALTHCARE FAMILY INSTITUTE FORM

Client Information

Date of Birth:    Gender: Male Female Other Prefer not to say

Emergency Contact

Insurance Information (if applicable)

Subscriber Name:    Relation to Client: Self Parent Spouse Other

Medical & Mental Health History

Chronic conditions (check all that apply): Diabetes Hypertension Heart disease Asthma Other:

Consent for Services and Treatment

By signing below, Client Name: authorizes Healthcare Family Institute and its licensed clinicians to provide assessment, psychotherapy, family therapy, and ancillary behavioral health services as deemed appropriate.

I understand that psychotherapy may involve discussing personal information and that no promises or guarantees have been made regarding outcomes. I acknowledge the clinician has explained common benefits and possible risks, including temporary increases in emotional distress, changes in relationships, and recall of painful memories.

I understand I may refuse or withdraw consent for treatment at any time, subject to clinical and legal obligations. Withdrawal of consent will not affect the handling of protected information already created by the clinician prior to the date of withdrawal.

Confidentiality and Limits

Communications with clinicians are confidential and protected by law except for specific, legally defined circumstances. Exceptions to confidentiality include: a) suspected abuse or neglect of a minor, elder, or dependent adult; b) a reasonable belief that the client poses imminent danger to self or others; c) court orders or subpoenas; d) information necessary for billing and claims processing when using insurance or third-party payors.

I authorize disclosure of protected health information to billing agents and to my insurance carrier as necessary to process claims. I understand that once disclosed to an insurer, information may no longer be protected from further disclosure by that insurer.

Release of Information

I authorize the release of information to the following individuals or agencies for coordination of care. If authorizing, specify scope and purpose below.

Authorization Expiration Date:    If no date entered, this authorization will expire one year from the date signed unless otherwise specified.

Telehealth / Remote Services

I consent to receiving services via telehealth modalities when clinically appropriate. I understand telehealth may have limitations including privacy risks, technological interruptions, and potential differences in clinical effectiveness. I acknowledge that I may decline telehealth and request in-person services where available.

Telehealth consent: I consent to telehealth services.

Administrative Acknowledgments

Notice of Privacy Practices: I acknowledge that I have been offered the Healthcare Family Institute's Notice of Privacy Practices and understand how my health information may be used and disclosed.

Financial Responsibility: I understand that I am financially responsible for charges not covered by insurance, including co-payments, co-insurance, and services denied by a third-party payer. I authorize payment of insurance benefits to the provider when applicable.

Emergency Procedures: In an emergency or if clinician reasonably determines imminent risk, clinicians may contact emergency services or other authorities without additional consent to ensure safety.

Client Statements

Acknowledgment and Signature

By signing below I certify that the information I have provided in this form is true and complete to the best of my knowledge. I have read and understand the foregoing consents, notices and authorizations and I accept their terms.

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