Client Intake Sheet

Annette A. Freel, M.S.

Please correct the errors described below.

Add new emergency contact:

Insurance Information (if Applicable)

Add new insurance information:

By typing my name, I confirm that the foregoing information is correct to the best of my knowledge and agree with the responsibilities stated above.

HIPAA Authorization to Release and/or Exchange Information

NOTE: This authorization complies with the requirements of the HIPAA Privacy Act

Add new emergency contact:

Add another provider:

The purpose for which the information will be used or disclosed: (the purpose may be stated as “at the request of the individual” if the individual initiates this authorization and does not provide a statement of purpose)

This authorization will expire on date given above or continue for the duration of treatment at Kentucky Psychological Services. I understand that I may revoke this authorization at any time, except to the extent the person/organization obtaining the authorization has already acted in reliance on it by contacting Kentucky Psychological Services in writing to express such revocation. By signing below, I acknowledge that I have read and understood this authorization and that it will continue for the duration of my treatment with Kentucky Psychological Services

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