Healthcare Psychosocial Document

Healthcare Psychosocial Document

Patient Information

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

Emergency Contact

Insurance Information

Presenting Problem & Clinical History

Onset of current concerns:    Course / Duration:

Psychiatric & Medical History

Substance Use

Use of substances (check all that apply):
Alcohol Cannabis Stimulants Opiates Tobacco / Nicotine Other

Social & Environmental History

Risk Assessment

Suicidal ideation / intent: Yes No

Homicidal ideation / intent: Yes No

Functioning & Strengths

Treatment Plan / Recommendations

Consent, Confidentiality & Authorization

I hereby consent to psychosocial assessment and treatment as indicated by the clinician. I understand that services may include assessment, psychotherapy, care coordination, and coordination with other providers where necessary to deliver care.

Limits of confidentiality: I understand that information disclosed in this assessment is confidential except where disclosure is required or permitted by law, including but not limited to: (1) imminent risk of harm to self or others; (2) suspected child, elder, or dependent adult abuse or neglect; (3) court order or subpoena; (4) information necessary for billing and payment to the insurer; or (5) other exceptions required by law. Clinician will make reasonable efforts to inform me prior to disclosures when permitted.

Authorization to communicate: I authorize the clinician and the care team to communicate and share relevant clinical information with treating providers and care coordinators involved in my care to ensure safe and effective treatment.

Telehealth: I consent to receive services by telehealth when clinically appropriate. I understand the risks, benefits, and alternatives to telehealth, including limitations related to privacy and technology.

Revocation: I understand that I may revoke this authorization at any time by providing written notice, except to the extent that actions have already been taken in reliance on this authorization. This authorization does not apply to information already disclosed under a prior signed authorization.

Authorization expiration: This authorization expires on:

I acknowledge receipt of the privacy practices and understand my rights related to my protected health information. I also understand that payment and treatment are separate and that refusing to sign this document will not affect my ability to receive emergency treatment.

I consent to psychosocial assessment, treatment, and the conditions stated above.

I authorize release of information to other health care providers and payers as necessary for treatment, payment, and care coordination.

I acknowledge the provider's privacy practices and my rights regarding protected health information.

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