Healthcare Psychological Consent Form

HEALTHCARE PSYCHOLOGICAL CONSENT FORM

Provider/Therapist:    Practice/Clinic:

Client Information

Male    Female    Non-binary    Other:    Prefer not to answer

Emergency Contact

Insurance Information

Medical & Psychological History

Consent for Psychological Treatment

I consent to receive psychological assessment, evaluation, and treatment from the above-named provider. I understand that treatment may include psychotherapy, psychological testing, behavioral interventions, skill-building, and case consultation as deemed appropriate by the provider. Services to be provided or discussed with the client:

I acknowledge that psychotherapy has potential risks and benefits. Benefits may include reduced symptoms, improved coping and functioning. Risks may include uncomfortable emotions, recall of painful memories, and temporary increase in symptoms. No guarantee is made regarding outcomes.

By checking the box below I confirm that the risks and benefits of treatment have been explained and I have had an opportunity to ask questions.
I acknowledge receipt of the explanation of risks and benefits.

Confidentiality & Limits

Communications between client and provider are confidential and records are protected by law. Exceptions to confidentiality include: (1) a credible threat of imminent harm to self or others; (2) suspected child, elder, or dependent adult abuse or neglect; (3) court order, subpoena, or other legal process; (4) when information is necessary to coordinate with other health care providers or third-party payers and disclosure is authorized by the client; (5) when required by law. I understand that if I disclose information that triggers mandated reporting or danger, the provider will take reasonable steps to protect safety.

I acknowledge and agree that the provider may consult with clinical supervisors or other professionals as necessary to provide appropriate care. Such consultations will preserve confidentiality to the extent possible.
I acknowledge the stated limits of confidentiality.

Telehealth / Communication / Recording

Telehealth: I understand telehealth uses electronic communications and that there are risks including technology failure, interruption, and potential loss of confidentiality. I may refuse telehealth and request in-person services where available. I agree to maintain privacy during sessions and to use a secure, private location.

I consent to participate in telehealth sessions when offered or necessary.

Recording: Audio or video recording of sessions will not occur without my separate written consent.
I consent to audio/video recording for treatment/education only (optional).

Release of Information & Billing

I authorize the provider to release and obtain information, as necessary, to process claims with insurance or to coordinate care with other health care professionals. I authorize release of protected health information necessary for billing, reimbursement, and quality assurance.

I authorize release of information for treatment, payment, and health care operations.

Voluntary Consent and Right to Withdraw

I understand that participation in psychological services is voluntary. I may refuse or withdraw consent at any time by providing written notice. Withdrawal of consent will not affect the provider's ability to bill for services provided prior to withdrawal nor will it affect any obligations to report imminent danger or abuse as required by law.

Authorization Expiration Date (if different from treatment consent duration):

Acknowledgment and Certification

By signing below I certify that I have read (or have had read to me) this consent form, that the information I have provided is accurate to the best of my knowledge, that my questions have been answered, and that I consent to the treatment and authorizations described above. I understand that this document constitutes a legal consent for psychological services and related releases as indicated.

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