PRACTICE SAMPLE CONSENT AND POLICIES FORMS

These are the consent forms that you may be asked to sign prior to starting services with us. Forms would depend on what applies to you. Also, depends on the payment option you choose, you may be asked to give us authorization to process your credit card payments.
 

 

CONSENT FOR COUNSELING AND PSYCHOTHERAPY

CONSENT FOR CHILD TREATMENT

If parents are separated or divorced, in addition to Consent for Child Treatment:

STIPULATION REGARDING LEGAL CUSTODY PROCEEDINGS

 

CONSENT FOR TELEHEALTH  CONSULTATION

PRACTICE POLICIES

HIPAA NOTICE FOR PRIVACY PRACTICES
 

Beginning January 1, 2022, healthcare providers must give self-pay clients a document called Good Faith Estimate Notice.
You can read that notice here:

 

GOOD FAITH ESTIMATE NOTICE

In case you want a therapist to release confidential information, we would ask you to fill out this form:

AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION