If you're a first-time client, please review and complete the following forms, bring them to your first session.
- Client Intake Form
- Limits of Confidentiality/Cancellation Policy Form
LIMITS OF CONFIDENTIALITY
The contents of a counseling, intake or assessment session are considered to be confidential. Both verbal and written records about a client cannot be shared with another party without the written consent of the client or the client's legal guardian. It is the policy of the office not to release any information about a client without a signed release of information. NOTED EXCEPTIONS ARE AS FOLLOWS:
DUTY TO WARN AND PROTECT
When a client discloses intentions or a plan to harm another person, the health care professional is required by law to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required by law to report this information to the appropriate social service and/or legal authorities.
PRENATAL EXPOSURE TO CONTROLLED SUBSTANCES
Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
MINORS/GUARDIANSHIP
Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.
INSURANCE PROVIDERS
Insurance companies and other third-party payers are given information that they request regarding services to clients. Information which may be requested includes type of services, dates/times of services, diagnosis, treatment plan, and description of impairment, progress of therapy, case notes, and summaries.
PROFESSIONAL MISCONDUCT
Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is held regarding the care professional's actions, related records may be released in order to substantiate disciplinary concerns.
COURT ORDERS
Health care professionals are required by law to release records of clients when a court order has been placed.
I agree to the above limits of confidentiality and understand their meanings and ramifications.
(when applicable)
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Client Signature (Client’s Parent/Guardian if under 18)
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Today’s Date
CANCELLATION POLICY
If you fail to cancel a scheduled appointment, we cannot use this time for another client and you will be billed for the entire cost of your missed appointment.
A full fee is charged for missed appointments or no show cancellations with less than a 24 hour notice unless due to illness or an emergency clients who do not show up for or cancel an appointment.
Thank you for your consideration regarding this important matter.
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Client Signature (Client’s Parent/Guardian if under 18)
________________________________
If you would like me to coordinate care with another provider (for example, your psychiatrist, endocrinologist, etc.), complete this form:
- Consent to Release Information Form
ABUSE OF CHILDREN AND VULNERABLE ADULTS
 Client Intake Form |
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| Confidentiality and Cancellation Policy |
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| Consent to Release |
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