Healthcare Play Therapy Document

HEALTHCARE PLAY THERAPY CONSENT AND INTAKE FORM

Client Information

Date of Birth:    Gender:

Primary Phone:    Secondary Phone:

Guardian / Responsible Party (if applicable)

Relationship to Client:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy/ID Number:    Group Number:

Medical & Developmental History

Play Therapy: Purpose, Methods, Risks and Benefits

Play therapy is a psychotherapeutic modality in which the clinician uses play, expressive materials, art, sandtray, puppetry, and symbolic techniques to assess and treat emotional, behavioral, social, and developmental concerns. The goals of play therapy are individualized and may include improving coping skills, emotional expression, social skills, and family relationships.

Common benefits include increased emotional regulation, improved communication, and symptom reduction. Potential risks include transient increases in distress as difficult feelings or memories emerge, possible changes in family dynamics, or the need for referral to additional services if concerns exceed the scope of play therapy.

Confidentiality and Its Limits

All information disclosed within sessions and the records pertaining to treatment are confidential and may not be released without written authorization, except as required or permitted by law. Exceptions to confidentiality include:

1. Reasonable suspicion of abuse or neglect of a child, dependent adult, or elder;
2. Imminent risk of serious harm to self (suicide) or others (homicidal intent);
3. When disclosure is required by a court order; and
4. When consulting with clinical supervisors or legal counsel as needed for client safety and quality of care.

Parents or guardians of minor clients generally have the right to access records, unless such access is determined by the clinician to be detrimental to the child's welfare. Custody or court-ordered restrictions regarding access to records should be documented below.

Authorization to Share Information

I authorize the therapist to share relevant treatment information with the following individuals or agencies for coordination of care, referral, or billing purposes. This authorization is voluntary and may be revoked at any time in writing, except to the extent action has already been taken in reliance on it.

Expiration of this authorization: . If left blank, authorization expires one year from the date of signature.

Telehealth, Recording, and Use of Materials

Telehealth sessions may be offered when appropriate. Audio or video recording of sessions will only occur with explicit written consent. Play therapy materials (art, sandtray items) are treated as therapeutic tools and not as formal assessments; physical items created during sessions may be stored temporarily for clinical purposes and returned or disposed of according to practice policies.

Consent for telehealth: I consent to telehealth services when recommended.    Consent for recording: I consent to audio/video recording for clinical supervision or treatment planning when explicitly agreed in writing.

Financial and Appointment Policy

Fees, co-pays, and billing arrangements will be discussed prior to treatment. Cancellation with less than 24 hours' notice may incur a late-cancellation fee. Insurance billing will include only the information necessary for claims submission; outstanding balances remain the responsibility of the insured or responsible party.

Acknowledgment and Consent

By signing below, I acknowledge that I have read and understand the information provided above and that I have had the opportunity to ask questions. I consent to participation in play therapy as described and authorize treatment by the therapist and their supervised staff. I understand that I may withdraw this consent in writing at any time, except to the extent that action has already been taken in reliance on it.

I specifically acknowledge and consent to the following (check all that apply):

I consent to use of expressive/play materials for assessment and treatment.
I consent to appropriate parental/guardian involvement as part of treatment planning and sessions.
I authorize referral to other health care providers when clinically indicated.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered or provided with a notice describing my rights under applicable privacy laws regarding protected health information and understand how my information may be used and disclosed for treatment, payment, and healthcare operations.

Acknowledgment of receipt: I acknowledge receipt of the privacy practices notice.

Additional Information

Sign Now