Client Forms

Family Information

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Informed Consent

  • Client-Therapist Service Agreement

    Welcome to my practice. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patients' rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very _important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future. Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in therapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

    Goals of Therapy

    There can be many goals for the therapeutic relationship. Some of these will be long term goals such as improving the quality of your life, overcoming and learning from past experiences or improving self-esteem. Others may be more immediate goals such as decreasing anxiety and depression symptoms, developing healthy relationships, changing behavior or decreasing/ending alcohol or drug use. Whatever the goals for therapy, they will be set by the clients according to what they want to work on in counseling. The therapist may make suggestions on how to reach that goal but you decide where you want to go.

    Risks/Benefits of Therapy

    Therapy is an intensely personal process which can bring unpleasant memories or emotions to the surface. There are no guarantees that counseling will work for you. Clients can sometimes make improvements only to go backwards after a time. Progress may happen slowly. Counseling requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions. However, there are many benefits to therapy. Therapy can help you develop coping skills, make behavioral changes, reduce symptoms of mental health disorders, improve the quality of your life, learn to manage anger, learn to live in the present and many other advantages


    Appointments will ordinarily be 50 minutes in duration as needed and determined by the nature of the therapy. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours' notice. If you miss a session without canceling, or cancel with less than 24-hour notice, you will be required to pay for the session [unless we both agree that you were unable to attend due to circumstances beyond your control]. Cancellations without adequate notice prevent me from filling the time slot with others who could use that time. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible the cancellation fee. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.


    Every effort will be made to keep your personal information private. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality to which you need to be aware. Consultation with another professional counselor may occur in order to give you the best service. In the event of consultation, no identifying information such as your name would be released. Counselors are required by law to release information when the client poses a risk to themselves or others and in cases of abuse to children or the elderly. If there is receipt of a court order or subpoena, I may be required to release some information. In such a case, I will consult with other professionals and limit the release to only what is necessary by law.

    Confidentiality and Technology

    Some clients may choose to use technology in their counseling sessions. This includes but is not limited to online counseling via Facetime, telephone, email or text. Due to the nature of online counseling, there is always the possibility that unauthorized persons may attempt to discover your personal information. Every precaution to safeguard your information will be taken but cannot guarantee that unauthorized access to electronic communications could not occur. Please be advised to take precautions with regard to authorized and unauthorized access to any technology used in counseling sessions. Be aware of friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used in your counseling sessions. If you wish, you can make scheduling arrangements via email. I do not do therapy or clinical work through email.

    Record Keeping

    I will keep records of your counseling sessions and a treatment plan which includes goals for your counseling. These records are kept to ensure a direction to your sessions and continuity in service. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section. Should the client wish to have their records released, they are required to sign a release of information which specifies what information is to be released and to whom. Records will be kept for at least 7 years but may be kept for longer.

    Professional Fees

    You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by cash, check or credit card If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required.


    I currently do not accept insurance. I will assist with filing claims for you to be able to be reimbursed. I will provide you with a statement indicating your clinical diagnosis and the CPT code for the service provided which will enable you to file for reimbursement out of network.

    Contacting Me

    I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If you feel you cannot wait for a return call or it is an emergency situation, go to your local hospital or call 911.

    Consent to Therapy

    Your signature below indicates that you have read this Agreement and agree to its terms.

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Informed Consent For Telepsychological Services

  • Prior to starting video-conferencing services, you must agree to the following:
    • There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.
    • Confidentiality still applies for teletherapy services, and nobody will record the session without the permission from the others person(s).
    • We agree to use the video-conferencing platform, Zoom for our virtual sessions, and the therapist will explain how to use it.
    • You need to use a computer, iPad or smartphone during the session.
    • It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
    • It is important to use a secure internet connection rather than public/free Wi-Fi.
    • It is important to be on time. If you need to cancel or change your tele-appointment, you must notify me in advance by phone or email.
    • We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
    • We need a safety plan that includes at least one emergency contact in the event of a crisis situation.
    • If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in teletherapy sessions.
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HIPPA Disclosure

  • In an effort to allow portability in health care insurance, increase resources to combat fraud and abuse, encourage electronic health care transactions and to create a national patient record privacy standard, Congress enacted the Health Insurance Portability and Accountability Act of 1996. This Act (known as HIPPA) created privacy standards, superceded a multitude of differing state laws and imposed requirements on all health care providers.

    HIPAA applies to any health care provider who transmits any health information in electronic form. Health care includes preventive, diagnostic, therapeutic, counseling, and related services, assessments or procedures with respect to the physical or mental condition.

    Health information includes any information, whether oral or recorded in any form or medium, that relates to the past, present or future mental health or condition of an individual.

    A health care provider that either provides treatment, and either maintains or uses individually identifiable health information may not use or disclose protected health information except as permitted by the regulations.

    A health care provider must make reasonable efforts to limit improper disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of the use disclosure or request.

    The act and ensuing regulations include mental health records. While psychotherapy notes are protected under HIPAA and the Texas Medical Records Privacy Act this does not mean that all psychotherapy records are excluded from required disclosure. Psychotherapy notes are generally exempt from subpoena and unwanted disclosure. It also does not mean they will not be requested or that you cannot authorize the disclosure. In certain circumstances information must be disclosed and in certain situations you are authorized to disclose or may seek that I resist unwanted disclosure. If this happens, we will need to discuss what rules apply and come to a decision on how it should be handled.

    If you want to authorize a disclosure in the future you will be provided a consent in plain language. I will not use or disclose protected information without a valid authorization.

    Limited and relevant disclosure and use is permitted when it is required by law. Some of these circumstances include, public health activities such as aversions of serious threats to health or safety or reports of child abuse or neglect to a public health authority or other appropriate government authority; or of abuse, neglect or domestic violence of the individual agrees or the provider, in the exercise of professional judgment, believes the disclosure is necessary to prevent serious harm to the individual or other potential victims.

    If you become involved in a Judicial or Administrative Proceedings, there are some circumstances in which a health care provider may be compelled to disclose otherwise protected information. If I receive a subpoena, I will let you know as soon as practicable and we will discuss further the legal requirements and options of how to respond.

    Reviewed and Acknowledged:

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Consent for the Release of Confidential Information

  • I understand that my records are protected under Federal and State Confidentiality Regulations. This authorization may be withdrawn at any time in writing except to the extent that the person who is to make this disclosure has acted on reliance on it. Upon revocation of consent, further Release of information shall cease immediately. I further acknowledge that the information to be release was fully explained to me and is given of my own free will.
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