Client Forms for Individual Psychotherapy
For my clients’ reference, I’ve provided here copies of the forms I regularly use to support the work we will do together. We will review all of these forms before signing them at our first meeting. Please ask me any questions you have about them.
- Starting Our Work Together Booklet: Psychotherapy Services Information and Contract – This booklet/contract provides important information about my professional services and business policies. It is also a legal document of informed consent and a binding contract between me and my client. Given the size and format of this booklet/contract, I mail it to new clients and ask that they read it and bring it with them to their first appointment.
For clients who have a printer, I ask that they print-out the following forms and documents. Alternatively, I will mail these to my new clients at their request. I ask that all my new clients read through these forms and documents, complete them (as needed), and bring them to their first appointment:
- Client History – With this form, clients provide me with information about their past and current experiences.
- Client Medical History
- Authorization to Release Confidential Information and Records – With this form, clients give consent to me to speak to another person about their history or treatment. In the event that a client would like this to occur, we will sign this form together after reviewing and specifying on the form the information that the client would like communicated. Any other aspects of the client’s treatment or life will remain confidential.
- Telepsychology Via Video Conferencing Agreement– a consent form
- Request and Consent for Transmission of Protected Health Information by Non Secure Means– a consent form
Health Insurance Portability and Accountability Act (HIPAA) Forms
- Notice of Privacy Practices (Unabridged Version) – Please read and bring to your first appointment. There is nothing for you to complete on this form.
- Notice of Privacy Practices (Brief Version) – Please read and bring with you to your first appointment. There is nothing for you to complete on this form.
- Consent to Use and Disclose Your Health Information – Please read and bring with you to your first appointment. With your signature on this form, you acknowledge that you have been informed about my procedures and practices to protect your privacy and that you have been informed about your privacy rights.
No Surprises Act Documents