Patient Forms

The following specifies your rights about this authorization under the Health Insurance Portability
and Accountability Act of 1996, as amended from time to time (“HIPAA”).

1. Tell your mental health professional if you don’t understand this authorization, and they will
   explain it to you.
2. You have the right to revoke or cancel this authorization at any time, except: (a) to the
   extent information has already been shared based on this authorization; or (b) this
   authorization was obtained as a condition of obtaining insurance coverage. To revoke or
   cancel this authorization, you must submit your request in writing to your mental health
   professional and your insurance company, if applicable.
3. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to
   obtain treatment, make payment, or affect your eligibility for benefits. If you refuse to sign
   this authorization, and you are in a research-related treatment program, or have authorized
   your provider to disclose information about you to a third party, your provider has the right
   to decide not to treat you or accept you as a client in their practice.
4. Once the information about you leaves this office according to the terms of this
   authorization, this office has no control over how it will be used by the recipient. You need
   to be aware that at that point your information may no longer be protected by HIPAA.
5. If this office initiated this authorization, you must receive a copy of the signed authorization.
6. Special Instructions for completing this authorization for the use and disclosure of
   Psychotherapy Notes. HIPAA provides special protections to certain medical records
   known as “Psychotherapy Notes.” All Psychotherapy Notes recorded on any medium (i.e.,
   paper, electronic) by a mental health professional (such as a psychologist or psychiatrist)
   must be kept by the author and filed separate from the rest of the client’s medical records
   to maintain a higher standard of protection. “Psychotherapy Notes” are defined under
   HIPAA as notes recorded by a health care provider who is a mental health professional
   documenting or analyzing the contents of conversation during a private counseling session
   or a group, joint, or family counseling session and that are separate from the rest of the
   individual’s medical records. Excluded from the “Psychotherapy Notes” definition are the
   following: (a) medication prescription and monitoring, (b) counseling session start and stop
   times, (c) the modalities and frequencies of treatment furnished, (d) the results of clinical
   tests, and (e) any summary of: diagnosis, functional status, the treatment plan, symptoms,
   prognosis, and progress to date.
   In order for a medical provider to release “Psychotherapy Notes” to a third party, the client
   who is the subject of the Psychotherapy Notes must sign this authorization to specifically
   allow for the release of Psychotherapy Notes. Such authorization must be separate from
   an authorization to release other medical records.

Initial Assessment

4. Current Family and Significant Relationships

6. Social Relationships

7. Cultural/Ethnic

8. Spiritual/Religious

9. Legal

10. Education

11. Employment/Vocational

12. Military

13. Leisure/Recreational

14. Physical Health

15. Chemical Use History

16. Counseling/Prior Treatment History

Cancellation Policy

If you fail to cancel a scheduled appointment, we cannot use this time for another client and you will be billed for the entire cost of your missed appointment.

A full session fee is charged for missed appointments or cancellations with less than a 24-hour notice unless it is due to illness or an emergency. A bill will be mailed directly to all clients who do not show up for, or cancel an appointment.

Thank you for your consideration regarding this important matter.

Authorization for Coordination of Behavioral Healthcare

Read this information first

You should complete this form if you wish to authorize your behavioral health provider to exchange information regarding your behavioral health condition to your primary care provider or other behavioral health providers who may be directly involved in making decisions regarding your health care. This authorization will remain in effect until the (a) date you specify; (b) one (1) year from date signed; or (c) the date you withdraw your permission.

Step 1: Complete the demographic information for the Provider administering services:

Step 2: Patient information (completed by Behavioral Healthcare Provider)

Step 3: Complete your acknowledgement that you understand that:

• You have the right to review the information that is being used or disclosed;
• You do not have to complete this authorization and your refusal will not affect your benefits unless this authorization is necessary to determine your benefits;
• The information used or disclosed by this authorization may be at risk for re-disclosure by the recipient and no longer protected by federal privacy laws;
• It is your responsibility to notify your Behavioral Healthcare Provider if you choose to change your Primary Care Physician;
• You have a right to revoke this authorization at any time; and
• A statutory privilege for confidential communications between a patient and a licensed psychologist exists. (For New Jersey residents only)

** Attach a copy of the appropriate legal document granting authority

Informed Consent for Psychotherapy

General Information
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

Confidentiality
The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person.
3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5. Suspected neglect of the parties named in items #3 and #4.
6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert's report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in
order to provide the best treatment for you. Information about you may be shared in this
context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you
first. Your right to privacy and confidentiality is of the utmost importance to me, and I do
not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more
than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy
discussions in public or outside of the therapy office.