Healthcare Therapy Profile

Healthcare Therapy Profile

Please complete this profile accurately. Information provided will be used for clinical assessment, treatment planning, and billing. All information is confidential except as limited by law (see Confidentiality and Exceptions section below). If a question does not apply, enter "N/A".

Patient Information

Patient Name:

Phone Email Text Message

Emergency Contact

Insurance / Billing Information

Medical & Mental Health History

Have you ever been hospitalized for psychiatric reasons? Yes No

Substance Use

Current use of:
Alcohol — frequency:
Tobacco — frequency:
Recreational drugs — type/frequency:

Safety & Risk Assessment

Current thoughts of harming self or others? Yes No

Therapy Information & Goals

Are you currently seeing any other mental health provider? Yes No

Consent, Confidentiality & Authorization

Consent for Psychotherapy: I authorize the clinician named to provide psychotherapy and related services. I understand that psychotherapy involves discussing personal information which can lead to emotional discomfort. Benefits may include improved coping, symptom relief, and behavioral change. Risks may include experiencing uncomfortable emotions or changes in relationships.

Confidentiality: Communications between patient and clinician are confidential and protected by law. Exceptions to confidentiality include: (1) reasonable suspicion of abuse or neglect of a child, dependent adult, or elder; (2) expressed intent to harm oneself or others (duty to warn and protect); (3) court order or other legal process; and (4) when information is necessary for third-party reimbursement or treatment coordination as authorized below.

Authorization to Release/Obtain Information: By checking the box below I authorize release of protected health information to the persons/organizations indicated for coordination of care, billing, or clinical communication. This authorization is valid until the expiration date provided or until revoked in writing.

I authorize release of information to:

Administrative Acknowledgments

Billing & Cancellation Policy: Fees, co-payments, and cancellation policies have been explained. Appointments cancelled without at least 24 hours' notice may be subject to a cancellation fee as permitted by clinic policy.

Emergencies: This practice does not provide emergency services. In case of immediate danger to self or others, contact local emergency services or go to the nearest emergency facility.

Acknowledgments:
I acknowledge receipt of billing and cancellation policy.
I acknowledge receipt of the privacy notice and my rights regarding protected health information.
I consent to treatment by the clinician and authorize communication for treatment and billing as specified above.

Optional: Other Authorized Contacts

I authorize the clinician to contact the above individual in case of emergency or as needed for care coordination. Yes

Patient Certification

By signing below, I certify that the information I have provided on this Healthcare Therapy Profile is true and accurate to the best of my knowledge. I have read and understand the foregoing statements regarding consent, confidentiality, and administrative policies. I understand I may withdraw my authorization to release information at any time by submitting written notice, except to the extent action has already been taken in reliance on this authorization.

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