Healthcare Therapeutic Process Form

HEALTHCARE THERAPEUTIC PROCESS FORM

This Therapeutic Process Form documents the intake information, proposed treatment plan, informed consent, and acknowledgments related to psychological, counseling, or other therapeutic services to be provided by the treating clinician. Patient Name: Date of Birth: Primary Therapist:

Patient Information

Female Male Other / Non-binary

Emergency Contact

Insurance and Billing

Medical & Behavioral Health History

Risk indicators (check all that apply):
Suicidal ideation or attempts Homicidal ideation or aggression Active substance misuse None reported

Presenting Problem & Treatment Plan

Proposed Modalities:
Individual therapy Group therapy Family therapy Telehealth / remote sessions Medication management

Risks, Benefits, and Alternatives

The clinician has explained the nature and purpose of the proposed treatment, customary benefits such as symptom reduction and improved functioning, and common risks including emotional distress when discussing traumatic material or change-related stress. Alternatives discussed include referral to psychiatry, higher level of care, or alternative therapeutic approaches. By checking the box below, I acknowledge that these items were discussed:

I acknowledge the clinician explained risks, benefits, and alternatives.

Confidentiality & Limits

Except where disclosure is permitted or required by law, all information disclosed within sessions is confidential. Exceptions include (1) imminent risk of serious harm to self or others, (2) suspected child, dependent adult, or elder abuse or neglect, (3) court order, and (4) when necessary for coordination of care with other identified providers to ensure patient safety. Minimal necessary information will be disclosed in such situations.

I acknowledge receipt of, or access to, the clinician's Notice of Privacy Practices which describes how my protected health information may be used and disclosed and how I may access this information. I acknowledge receipt.

Release / Exchange of Information

If coordination of care or billing requires disclosure, I authorize the release of pertinent mental health information to the entities or persons identified below for the purposes of treatment, care coordination, or insurance processing. This authorization includes the exchange of clinical summaries, diagnosis, treatment recommendations, and limited substance use or medication history when necessary.

I understand I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance upon it.

Fees, Payment & Cancellation

Standard fee per session and payment responsibility have been explained. Insurance may be billed only with the patient's authorization and patient remains responsible for co-payments, deductibles, and charges not covered by insurance. Cancellation less than 24 hours before a scheduled session may incur a cancellation fee.

I acknowledge the cancellation and no-show policy and accept financial responsibility as described.

Telehealth / Remote Services

Telehealth involves delivery of services using interactive audio and video. Potential benefits and risks were discussed, including confidentiality risks outside the clinician's control. If telehealth is used, I agree to a private environment and stable internet connection. By checking below I consent to telehealth services:

I consent to receive therapeutic services via telehealth.

Informed Consent and Acknowledgment

By signing below I confirm that I am the patient or the patient’s legally authorized representative. I have had the opportunity to ask questions and have received satisfactory answers. I voluntarily consent to participate in the therapeutic process described herein. I understand that I may withdraw this consent at any time in writing, except where clinical safety concerns require otherwise.

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