Clients Psychotherapy Intake Forms A, B (additional participants) and C (release of information)


Please correct the errors described below.

(ALL participants need to read, fill out, sign and submit ALL forms below)


Under the 1996 Health Insurance Portability and Accountability Act (HIPAA), you have specific Privacy Rights, as a client. The purpose of this form is to notify you of them:

  1. The right to inspect your own health information and obtain a copy (excluding psychotherapy notes).
  2. The right to request an amendment to health information (excluding psychotherapy notes).
  3. The right to receive an accounting of disclosures for purposes other than treatment, payment and healthcare operations.
  4. The right to request uses and disclosures of health information be restricted.
  5. The right to file a privacy complaint with your provider, the Office of Civil Rights (OCR) and/or the secretary of HHS (Department of Health and Human Services). You must do it in writing and you may either give it to me, at your next appointment, or send it by mail. To file a complaint with the Secretary of HHS, you may get assistance via the internet at, you may email them at or call HHS, toll-free, at: 1-800-368-1019. If you choose to mail it, confirm the following address: HIPAA Complaint 7500 Security Blvd, C5-24-04 Baltimore, MD 21924.
  6. The information needed to file a complaint is your contact information (name, address, and phone), the name of the Covered Entity you are filing the complaint about, their tax identification #, Medicare identification #, if applicable, their address and phone number.

As your provider, I am legally required, under Federal Law and HIPAA, to protect your health data and to release only the minimum necessary information for the purposes of treatment, payment or healthcare operations, unless otherwise specifically authorized by you.

Confidentiality - No one will reveal information concerning your counseling to anyone outside of this office except as follows: (1) You consent it in writing; (2) if life or safety is seriously threatened (including abuse of children/elderly/disabled); (3) disclosure is required by law (such as a judge requesting records); (4) you file a benefit claim and the claim payer or your insurance requires information; (5) the files are audited by Quality Assurance bodies; (6) or the IRS; (7) I choose to disclose anonymous information pertaining to your case for the purpose of clinical and professional consultation, personal publication and/or educational illustration; (8) if, through the use of an encrypted email, fax or phone, your information, inadvertently, falls in the hands of someone other than the one intended; (9) other people who may have limited access to your file and/or may learn of your name associated with our counseling relation may include, but not be limited to: anyone working for me, the bank, collections, bankruptcy court, office staff/cleaning crew/landlords/representatives, personnel related to building emergencies, such as firemen.

Fees - Professional services are due when rendered. Please refer to my website for specific services amounts ( Your signature below will indicate that you accept full responsibility for payment of any balance incurred for services; that you further understand that without two-(or three, if a 2-hr-appointment) full-business-days-notice of intention to cancel, that you will be charged for the full professional fee. E.g.: a Monday appointment needs to be canceled early Thursday or late Wednesday, the week prior. If you have health insurance plans, at no charge to you and, as a courtesy, I will bill them and collect from you your co-pay and/or deductible (in cash, check or card), if applicable. It is your responsibility to understand your insurance plan, keep up with your specific benefits and inform me of it and of any changes.

Video or phone consultations are billable the same or according to my hourly rate (e.g. 15 minutes = $50). Check with your insurance if your plan allows for telehealth. Any of my time dedicated to legal matters is billed at the $375/hr. rate. Non-payment of fees may result in termination of professional services and initiation of collection activity ($40 additional fee).

Parents/legal guardians: your signature below is your acknowledgment that if your child is 18 years old or older, but brought here by you, that you are ultimately responsible for the bills.

Furthermore, the Law requires both parents' signature in the treatment of minors; your signature below is not only your permission of my treatment of your child but also your acknowledgement that you have full legal authority to consent it, without obtaining approval of another person.

Regular email and text messages are not permitted, per Hipaa; only encrypted, which I initiate.

Your signature below is proof that you fully understand this form and accept it as the terms of your participation in this counseling. All of the above remains in effect until revoked by you in writing; should there be any changes to these forms, provided you are still actively involved in therapy, you will be notified and given new ones to sign, as well as a copy.

You assign the following person as your emergency contact and hold Rosario Ortigao harmless, should the need arise to notify the person below:

Generalized Consent

I hereby give my consent for Rosario Ortigao and her business associates to use and disclose my protected health information (PHI) to a third party for the purpose of carrying out "treatment," "payment" and "health care operations." I understand that, otherwise, in order for my therapy notes to be released to any party, I have to sign an "Authorization for Release of Information" form ( I also understand that I have the right to request restrictions on how and to whom my PHI may be released.

No Surprises Act

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost (please refer to my website for more information, and

On the day of your appointment and beyond, you will be receiving an assessment and psychotherapy services from me at $250 (the first one or two sessions) and $375 for sessions longer than 53+ minutes. A no show or a late cancellation (less than two-full-business days) will be charged $250/$220/$200/$300/or $375 depending on the type and length of session (please refer to my website for more information, and ). Any extra paperwork, consulting, emails, documents producing or reading is also charged at $200/hr. Legal-related matters are charged at $375/hr. After an assessment is made and a treatment plan is developed and discussed with you, the length of treatment depends on many factors such as need, availability, life circumstances; typically, clients come weekly or bi-weekly for a year or more; frequent conversations will be had linking your goals, my recommendations and our plan of action. I shall discuss your diagnosis with you during or after our 1st visit.

I fully understand what I have just read and acknowledge that I am saving a copy of this legal document for myself.

* I agree that my initials and my electronic signature on this document should be given the same legal force and effect as a handwritten signature (i.e., it is as valid as if I signed the document in writing).




I authorize the practice of Rosario Ortigao, L.M.H.C., to keep my signature on file and charge my credit card account for all sessions related to my treatment (with me present or not, e.g., my partner or child came without me):

  • Charges for attended appointments (co-pays or full fees for rendered services).
  • Charges for missed appointments (no-shows or late cancelations, i.e., those not canceled with two-full-business days).
  • Unpaid insurance balance with more than 90 days.

I understand that I may revoke this agreement at any time by providing a request in writing.

* I agree that my electronic signature on this document should be given the same legal force and effect as a handwritten signature (i.e., it is as valid as if I signed the document in writing).










Please check the box if you are PRESENTLY experiencing any of the symptoms below.

Please add a star (*) next to those that have been going on a long time

(6 months or more for adults, 3 months or more for children)



(this is the only form whose information I'll ask you to bring to each session)

Looking back over the last week or two, including today, on a 0-10 scale, help me understand how you have been feeling, by rating how well, or not, you have been doing in the following areas of your life:

Marks to the left represent low levels (zero: the worst) and marks to the right indicate high levels (10: the best).




(Please note that EACH additional participant needs to fill out the remaining forms; as well as sign the Notice of Privacy Rights and Practices, the General Consent and No Surprises Act form, the credit card information form, if different, and the ORS form, all of which are found previously, at the beginning of this document)


ADDITIONAL PARTICIPANT'S CURRENT SYMPTOMS: Please check the box if you are PRESENTLY experiencing any of the symptoms below. Please ADD a star (*) next to those that have been going on a long time (9 months or more for adults, 3 months or more for children).



I request and authorize Rosario Ortigao to RELEASE to and/or OBTAIN information from:

I authorize the above named agency, persons or office to release/obtain (fill in your initials, please):

I hold Rosario Ortigao LMHC harmless in regards to the use of information authorized for release of exchange. I understand that this form is not required as a condition for treatment and that it may be revoked by me in writing, at any time, except to the extent that action has already been taken. In the absence of revocation, this authorization will expire one year from the date of my signature or when my treatment ends. This authorization is for records protected under the privacy regulations of HIPAA (the Health Insurance Portability and Accountability Act) and by Federal Confidentiality rules (42 CRF Part 2). A copy of this authorization is as authentic as the original signed Authorization to Release/Obtain Information form. The original will be sent to Rosario Ortigao for my medical records' file, and I will keep my own copy (initial below). I fully understand what I just read.

* I agree that my initials and my electronic signature on this document should be given the same legal force and effect as a handwritten signature (i.e., it is as valid as if I signed the document in writing).

Your information will be encrypted.