Healthcare Therapeutic Services Form

Healthcare Therapeutic Services Form

Patient Information

Emergency Contact

Insurance Information

Subscriber Date of Birth:

Medical & Mental Health History

Requested Services and Preferences

Type of Service Requested:

Preferred Frequency:    Session Length:

Requested Start Date:

Consent for Therapeutic Services

I, the undersigned, consent to receive therapeutic services including assessment, diagnosis, treatment planning, psychotherapy, and related clinical services from authorized clinicians. I understand that:

• Therapy involves discussing personal information and may produce emotional distress, but may also result in benefit and improved functioning.
• Treating clinicians will use clinically appropriate methods and will document services in a clinical record maintained by the practice.
• I may refuse any recommended treatment and may withdraw consent at any time by providing written notice; withdrawal will not affect release of records or disclosures already made in reliance on this authorization.

Consent to Treatment: I give informed consent to receive therapeutic services as described above.

Telehealth Consent (if applicable)

Telehealth involves delivery of clinical services using electronic communications. Telehealth may include video, audio, and messaging. There are benefits and limitations to telehealth, including potential technical failures and confidentiality risks.

Telehealth Consent: I consent to receive services via telehealth and agree to the use of reasonable technical measures to protect confidentiality.

Authorization for Release of Medical Information

I authorize the release of my medical and mental health information, including diagnostic, treatment, and billing records, to the following person(s) or entities for the purpose of coordination of care and billing:

Scope of Authorization: Treatment Information Billing/Payment Other:

This authorization is valid until: Unless earlier revoked in writing. I understand that information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations.

Financial Responsibility & Assignment

I accept financial responsibility for services rendered. I authorize my insurer to pay benefits directly to the treating provider when applicable. I understand that I am responsible for copayments, deductibles, and any charges not covered by my insurance. If my account is referred for collection, I may be responsible for reasonable collection and legal costs.

Assignment of Benefits: I assign benefits to the provider and authorize billing of insurance for services rendered.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered a copy of the practice's Notice of Privacy Practices describing how protected health information may be used and disclosed, and how I may obtain access to this information. I understand my rights with respect to my protected health information and elect to:

Accept that I have received or been offered the Privacy Practices notice. Decline to acknowledge receipt at this time.

Additional Consents & Notices

Emergency Contact Permission: I authorize clinicians to contact my emergency contact in the event of a safety concern.

Limits of Confidentiality: I understand that confidentiality has legal exceptions, including but not limited to: imminent risk of harm to self or others, suspected abuse/neglect of a minor or dependent adult, and court-ordered disclosures. Clinicians will make reasonable efforts to discuss these limits with me.

Acknowledgment and Signature

By signing below, I certify that the information I have provided is accurate to the best of my knowledge, that I have read and understand this form, and that I consent to the terms herein. I understand I may revoke authorizations in writing, except to the extent disclosures have already been made in reliance on this authorization.

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