Healthcare Well Life Therapy Consent Form

Healthcare Well Life Therapy Consent Form

Patient Information

Patient Name:    Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical & Mental Health History

Primary Care Provider:    Phone:

Are you currently under psychiatric care? Yes No    If yes, treating clinician:

Consent for Psychotherapy and Related Services

I authorize Well Life Therapy and its licensed clinicians, trainees, and authorized staff to provide psychotherapy, counseling, assessment, and related mental health services. I understand that therapy involves discussing personal information and that progress cannot be guaranteed. I acknowledge that therapy may involve emotional discomfort, changes in relationships, or increased awareness of unpleasant aspects of my life.

I have been informed of common risks and benefits. Benefits may include improved coping, symptom reduction, and increased insight. Risks may include temporary worsening of symptoms, distress when discussing difficult material, and unforeseen interpersonal effects. Alternatives to psychotherapy include medication management, medical evaluation, or other community services.

Limits to confidentiality: I understand that therapists must break confidentiality when required by law, including but not limited to imminent risk of harm to self or others, suspected abuse or neglect of minors, elders, or dependent adults, and when disclosure is required by court order. Additional disclosures may be made with my written authorization.

Telehealth: I consent to receive services via telehealth (video or telephone) where appropriate. I understand telehealth has benefits and risks distinct from in-person care, including potential technology failures and privacy limitations. I may revoke telehealth consent at any time.
Telehealth Consent: I consent to telehealth services.

Authorization to Release or Obtain Records

I authorize Well Life Therapy to release to and/or obtain from the person(s) or organization(s) named below protected health information related to treatment, diagnosis, and billing for the period specified. This authorization is voluntary and may be revoked in writing except to the extent action has already been taken.

Purpose of disclosure:    Expiration Date:

Billing, Assignment of Benefits & Insurance

I authorize my clinician to submit claims to my insurance carrier and to release information required for billing. I assign benefits to be paid directly to Well Life Therapy where applicable and understand I remain ultimately responsible for any charges not covered by insurance.

Assignment of Benefits: I authorize payment of benefits to Well Life Therapy.

HIPAA Privacy Acknowledgment

I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices describing how my health information may be used and disclosed, and how I can access this information. I understand that I may request restrictions on certain uses or disclosures, and that such requests will be considered but not guaranteed.

Acknowledgment of Receipt: I acknowledge receipt of the Notice of Privacy Practices.

Consent for Minors and Guardianship

If the patient is a minor or otherwise represented, a parent or legal guardian must sign. The signer certifies they are the parent or legal guardian and have authority to consent to mental health treatment for the patient. Guardian relationship:

Statements of Understanding (Initials)

I understand the nature of therapy, risks and limits of confidentiality. Initials:    I consent to telehealth if indicated. Initials:    I authorize release of limited records to insurance. Initials:

Patient Certification

By signing below, I certify that I have read and understand the foregoing information, that the facts stated on this form are true to the best of my knowledge, and that I consent to treatment under the terms described. I understand I may revoke this authorization in writing except where action has already been taken in reliance on it.

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