Healthcare LICSW Form

HEALTHCARE LICSW FORM

Client Information

Emergency Contact

Insurance / Billing Information

Presenting Concerns & Clinical History

Risk Screening

Within the past month, have you experienced thoughts of harming yourself? Yes No

Within the past month, have you experienced thoughts of harming others? Yes No

Current substance use that affects functioning? Yes No

Consent for Services (LICSW)

I authorize Licensed Independent Clinical Social Worker (LICSW) to provide assessment, psychotherapy, counseling, and related clinical services. Services may include individual, family, or group psychotherapy, brief structured interventions, case coordination, and written documentation. I understand that treatment is collaborative and I may refuse or withdraw consent at any time, except as limited by law or by obligations to protect safety.

Benefits: Psychotherapy may reduce distress, improve functioning, and increase coping skills. Risks: Participation may temporarily increase unpleasant feelings, memories, or stress as issues are addressed. There is no guarantee of specific results.

Alternatives: I understand alternatives may include medication, other therapy modalities, or no treatment. I have had an opportunity to ask questions and discuss alternatives.

Confidentiality & Limits

Communications with my LICSW are confidential and will not be released without my written authorization except in the following legally required or permitted circumstances: (1) suspected child abuse or dependent adult/elder abuse; (2) reasonable suspicion of imminent risk of harm to self or others (duty to warn/protect); (3) court order or other legal process; (4) referral for services when required for coordination of care or billing; (5) when I sign a written release of information. The LICSW may consult with other clinical professionals for case supervision or consultation; such consultants will be bound to maintain confidentiality.

Telehealth & Electronic Communication

I consent to psychotherapy services delivered via telehealth when appropriate. I understand telehealth involves electronic transmission of information and carries risks including interruptions, unauthorized access, and technical failure. I consent to use of secure communication methods when available, and to limited use of standard electronic communication (telephone, text, email) for scheduling and care coordination. I understand emergencies are not appropriate for electronic communication.

Release of Information / Authorization

I authorize the LICSW to release and obtain protected health information as necessary for treatment, payment, and care coordination to the following recipient(s) for the purpose(s) indicated below.

I understand I may revoke this authorization at any time by written notice except to the extent action has already been taken in reliance on it. Information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by privacy law.

Fees, Insurance & Cancellation Policy

Fees for services, co-payments, and session length will be discussed during intake. I authorize the LICSW or practice to submit claims to my insurance and to release information necessary for payment. I understand that I am financially responsible for charges not covered by insurance, including co-pays, deductibles, and any non-covered services.

Cancellation: I agree to provide at least 24 hours' notice to avoid a late cancellation or missed appointment fee. Repeated missed appointments may result in termination of services.

Acknowledgment & Consent

By signing below I acknowledge that I have read and understand the information provided above regarding services, confidentiality and its limits, telehealth, release of information, fees, and cancellation policy. I consent to receive clinical services from a Licensed Independent Clinical Social Worker (LICSW) and authorize the use and disclosure of my protected health information as described in this form.

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