Adolescent Intake Form
The intake form provides me with information about you, your family, history, presenting problem, and associated symptoms. Please be advised that if you share custody of your adolescent, you will need to provide legal documentation that you have primary custody. Otherwise, both parents holding custody rights will be required to sign the Informed Consent prior to treatment.
Adult Intake Form
The intake form provides me with information about you, your family, presenting problem, history, and associated symptoms.
Couples Intake Form
The intake form provides information about you, your family, presenting problem, history, and associated symptoms.
Informed Consent / HIPPA
Declaration of Practices / Informed Consent
In order to assure that you are informed and protected, a statement of practices is provided for you.
HIPPA Notice of Privacy Practices
Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) is a Privacy Rule issued by U.S. Department of Health and Human Services to address the use and disclosure of individuals’ protected health information.
Couples Consent Release
Information obtained from an adult client individually may NOT be shared with anyone without written consent. Information may be released ONLY with the client’s spouse or other family members with the client’s written permission. Clients may refuse to provide written permission to waive confidentiality rights between or among each other. Please be advised that withholding information from each other during couple or family therapy could impede or even prevent a positive outcome to therapy.
General Consent Release
Materials revealed in counseling will remain strictly confidential except for the following circumstances, in accordance with State law: the client signs a written release of information indicating informed consent of such release; the client expresses intent to harm him/herself or someone else; there is a reasonable suspicious of abuse/neglect against a minor child, an elderly person (60 or older), or a dependent or disabled adult; a court order is received directing the disclosure of information.
It is critical for parents/guardians and adolescents to discuss, clarify, and provide expectations to me regarding information disclosed during session. Any material obtained from a minor client may be shared with the client’s parent or guardian. However, please be reminded that trust is essential for the therapeutic process.
Financial / Insurance
The financial policy provides clarification and protocol for your financial obligations specific to the session rate and cancellation protocol.
Credit Card Authorization Form
This form represents an agreement to allow Present Hope Counseling, LLC the right to charge your credit card for payment or cancellations in accordance to the financial policy.
Medical Insurance / Health Insurance Form
This form provides you with questions you will need to ask your insurance provider and represents an agreement to allow Present Hope Counseling, LLC the right to submit claims to your insurance provider.