Healthcare Therapy Handbook

HEALTHCARE THERAPY HANDBOOK

Patient Identification

Patient Name:

Date of Birth:   Gender:

Emergency Contact

Insurance Information

Medical & Clinical History

Administrative Policies

Fees, billing, and payment responsibility: The patient is financially responsible for all charges for services rendered. Insurance is billed as a courtesy to the patient; any balance not covered by insurance, including co-payments, co-insurance, deductibles, or non-covered services, is the responsibility of the patient or guarantor. Standard copay amount:

Cancellations and no-shows: Appointments canceled less than 24 hours in advance or missed appointments may incur a fee. No-show fee (if applicable): . Repeated no-shows may result in termination of services.

Appointment reminders: I consent to receive appointment reminders via (check all that apply):

Consent to Treatment

I authorize the clinician(s) to provide behavioral health services, including assessment, psychotherapy, care coordination, and consultation. These services may include talk therapy, behavioral interventions, and brief medication management coordination where applicable. I acknowledge that no specific outcome is guaranteed and that I may withdraw consent at any time, subject to clinician discretion and safe transfer arrangements.

Telehealth Services

Telehealth (video or phone sessions) may be offered when clinically appropriate. Telehealth differs from in-person care and may involve limitations such as technology disruption, privacy risks, and inability to provide hands-on emergency interventions. Emergency contact procedures will be confirmed prior to a telehealth session.

Confidentiality and Limits

All clinical information is confidential and will not be released without written authorization except as required or permitted by law. Limits to confidentiality include: risk of imminent harm to self or others; suspected child, elder, or dependent adult abuse or neglect; court order; and when information is required by law for third-party payment or to coordinate care. Clinicians will make reasonable efforts to limit disclosure to the minimum necessary information.

HIPAA Privacy Acknowledgment

I acknowledge receipt of the Notice of Privacy Practices describing how my protected health information may be used and disclosed, and how I can access this information. The notice explains my rights with respect to protected health information and the practice's legal duties.

Authorization to Release Information (Optional)

I authorize the release of protected health information to facilitate coordination of care, payment, or other purposes I specify below. This authorization is voluntary and may be revoked by me in writing, except to the extent that action has already been taken in reliance upon it.

Emergencies and Safety

In the event of an emergency or imminent risk, the clinician will follow established protocols, which may include contacting emergency services or the patient’s emergency contact. The practice is not an emergency facility. If you are experiencing a life-threatening emergency, contact local emergency services immediately.

Patient Rights and Responsibilities

Patients have the right to respectful, nondiscriminatory care; to participate in treatment planning; to request amendment of their records; and to withdraw consent for treatment. Responsibilities include providing accurate information, attending scheduled appointments, and informing the clinician of changes in condition or contact information.

Complaints and Grievances

If I have a complaint regarding services, billing, or privacy practices, I may raise the concern with the clinician or administrative staff. The practice will document, investigate, and respond to grievances in a timely manner consistent with applicable policy and law.

Minor / Guardian Information (if applicable)

By signing below, I acknowledge that I have read, understand, and agree to the policies, consents, and acknowledgments contained in this Healthcare Therapy Handbook. I understand that this document is an agreement between the patient (or guardian) and the treatment practice, and that I am responsible for fees as described above.

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