Healthcare Therapy Services Form

HEALTHCARE THERAPY SERVICES FORM

Patient Information

Date of Birth:    Gender: Male Female Non-binary Other

Preferred contact method: Phone Email Mail

Is patient a minor or under legal guardianship? Yes

Insurance Information

Emergency Contact

Medical & Mental Health History

Have you previously received mental health or substance use treatment? Yes No

History of suicidal ideation, attempts, or self-harm? Yes No

Treatment Goals & Preferences

Preferred therapy modalities (check all that apply):
CBT EMDR Psychodynamic Group Family Telehealth

Consent for Treatment

I authorize the provision of psychotherapy, counseling, or other clinical services as determined appropriate by my therapist. I understand that therapy involves discussion of personal issues and that benefits are expected but not guaranteed. I understand common risks include experiencing uncomfortable emotions, changes in relationships, and temporary increases in symptom intensity during the course of treatment.

I understand that I may withdraw consent to treatment at any time. Termination of therapy by the clinician may occur when the clinician determines that treatment goals have been achieved, or if clinical or safety issues arise that require transfer of care. I acknowledge that emergency contact, crisis, or safety planning steps will be reviewed with me as appropriate.

Confidentiality & Limits

Except as required or permitted by law, information disclosed in therapy is confidential. Exceptions where confidentiality may be breached without prior authorization include: (1) suspected child abuse or neglect; (2) suspected abuse of vulnerable adults or elders; (3) credible threat of imminent harm to self or others; (4) court order or subpoena; and (5) when coordination of care requires disclosure to other treating providers for safety. If disclosure is necessary, only information essential to the purpose will be released.

Telehealth & Electronic Communication

Telehealth involves delivery of services via electronic means. Telehealth may present risks including technology failure, privacy limitations, and unauthorized access. By checking the box below, I consent to receive services via telehealth and to the use of electronic communication for appointment scheduling and brief clinical correspondence.

I consent to telehealth services and electronic communication.

Release of Information Authorization

Authorization expiration date:

I authorize the release of the specified information to the named party for the stated purpose. I understand I may revoke this authorization in writing except to the extent that action has already been taken in reliance on it.

Financial Agreement & Cancellation Policy

I understand my financial responsibility for services rendered. Consultation, intake, and subsequent sessions may be billed to insurance when appropriate and only with valid authorization. If insurance denies payment, I am responsible for payment in full.

Late cancellations and no-shows may be charged the stated cancellation fee. Repeated missed appointments may result in termination of services. Payment is due at time of service unless other arrangements are approved in writing.

I agree to accept financial responsibility as stated above.

HIPAA Acknowledgment

I acknowledge that I have been offered a copy of the Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights with respect to that information. I understand I may request restrictions and obtain a copy of my records according to applicable law.

I acknowledge receipt of the Notice of Privacy Practices (or declined to receive a copy).

Patient Rights & Emergency Instructions

In the case of an emergency or imminent risk of harm, call local emergency services or proceed to the nearest emergency facility. For non-urgent matters outside business hours, use the provided emergency contact procedures discussed with your clinician.

Optional: Additional Notes

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