Healthcare Psychological Aid Form

Healthcare Psychological Aid Form

Patient Information

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

Emergency Contact

Insurance Information

Medical & Psychiatric History

Current Concerns & Symptoms

Please indicate current experiences (check all that apply):

Depression    Anxiety    Panic Attacks    PTSD
OCD    Mood Swings    Sleep Disturbance    Appetite Change
Memory/Concentration Problems    Psychosis / Hallucinations    Other

Risk Assessment

Current suicidal thoughts: Yes No    Current homicidal thoughts: Yes No
History of self-harm or attempts: Yes No

Substance Use

Current use: Alcohol Tobacco Illicit drugs Prescription medication misuse

Consent for Psychological Treatment

I voluntarily consent to evaluation and psychological treatment, including psychotherapy, assessment, and behavioral interventions provided by licensed clinicians or supervised trainees. I understand that psychotherapy involves discussing personal information and that no guarantees have been made regarding outcomes. I acknowledge that benefits may include symptom reduction, improved functioning, and better coping; risks may include experiencing uncomfortable emotions, shifts in relationships, or temporary increase in symptom awareness.

I understand I have the right to ask questions, refuse specific treatments, and withdraw consent at any time. Withdrawal of consent will not affect any rights related to past actions taken by the clinician prior to notice of withdrawal.

I acknowledge that I have read and understand the above statements and consent to psychological treatment.

Confidentiality & Limits

Information disclosed in treatment is confidential and will not be released without written authorization except as required or permitted by law. Exceptions include: reasonable belief of imminent risk of serious harm to self or others; known or suspected abuse or neglect of children, elders, or dependent adults; court-ordered disclosure; or where mandated reporting is required. If records are submitted to an insurer or third party for payment, some clinical information may be disclosed as necessary for billing.

Authorization to Release / Obtain Records

Purpose of disclosure:

Expiration date of this authorization (or 'on completion of treatment'):

Telehealth & Communication Consent

I consent to receive psychological services via telehealth when clinically appropriate. I understand risks and limitations, including technology failures and potential privacy risks.

Contact & reminders (check all that apply):
Phone call reminders    Permission to leave voicemail    SMS/text reminders    Email reminders

Fees, Cancellation & Emergency Policy

Patient is responsible for applicable co-pays, co-insurance, and any fees not covered by insurance. Cancellation policies apply; failure to provide notice may result in a cancellation fee. In emergencies or life-threatening situations, contact local emergency services or proceed to the nearest emergency department. Clinicians may provide limited emergency assistance but are not a 24-hour crisis service unless otherwise contracted.

I acknowledge the fee, cancellation, and emergency policies as stated above.

Patient Certification & Acknowledgement

I certify that the information I have provided on this form is correct to the best of my knowledge. I understand and accept the policies, consents, and limits described in this document. I authorize provision of care consistent with the consents granted above.

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