Healthcare Trauma Application

HEALTHCARE TRAUMA APPLICATION

Patient Information

Patient Name:

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

Emergency & Referral

Insurance and Billing

Incident Details

Date of Incident:    Location of Incident:

Medical and Mental Health History

Current Symptoms and Functioning

Please check all symptoms that apply:

Consent for Evaluation and Treatment

I authorize and request that the trauma program conduct an initial clinical evaluation and provide trauma-focused assessment and treatment as clinically indicated. I understand that treatment may include psychological assessment, evidence-based psychotherapeutic interventions, medication management referral, safety planning, and coordination with other providers as needed.

I acknowledge that I have been informed of the potential benefits and risks of trauma-focused treatment, including but not limited to increased emotional distress when processing traumatic memories, temporary symptom exacerbation, and the possibility that specific interventions may not achieve complete symptom resolution. I understand that my participation is voluntary and that I may withdraw consent at any time, subject to the clinician’s duty to act if I pose an imminent risk to myself or others.

Limits of confidentiality include: mandatory reporting of child or elder abuse, reasonable belief of imminent harm to self or others, and disclosures required by court order. Information necessary for billing and coordination of care with my insurer and other treating providers may be disclosed as needed for payment and treatment purposes.

Authorization to Release Records & Billing

I authorize the release of my protected health information, including diagnosis, treatment summaries, and selected records relating to this trauma assessment and treatment, to the following persons or agencies for purposes of treatment, continuity of care, or billing:

I understand this authorization is voluntary and that I may revoke it in writing at any time, except to the extent that action has already been taken in reliance on this authorization. Unless revoked earlier, this authorization will expire on the date specified below or one year from the date of signature if no date is provided.

Privacy Notice Acknowledgment

I acknowledge that I have received or been offered a written notice describing privacy practices governing the use and disclosure of my health information and that I have the right to request restrictions on certain uses and disclosures. I understand that refusal to consent to treatment will not affect my access to emergency services.

Emergency Contact & Safety

If at any time I am assessed to be at imminent risk of harming myself or others, I understand that the clinician will implement safety measures which may include emergency contact notification, hospitalization, or contacting emergency services.

Certification

By signing below, I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that providing false information may jeopardize appropriate clinical care and insurance claims. I consent to the evaluation and authorizations described above and understand my rights regarding revocation and limits of confidentiality.

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