State statute requires that each adult in a therapy session be provided with 1.) A Medical Information Intake form, 2. A disclosure form on the Limits of Confildentiality in professional counseling, 3.) A Consent to Treatment form, and 4.) A Personal Disclosure Statement of the healthcare provider's policies, procedures, and theoretical approach to therapy, as well as licensing affiliations.
Thank you for scheduling with our office. We look forward to meeting you soon!
Each adult planning to attend the therapy session should print, read, and sign one Intake document each (below) and bring along. Adults coming with a minor child will bring one completed Intake form and the Parent/Child Information form to the first session, attended with your minor child at the initial meeting.
Please call the mental health provider listed on the back of your insurance card (or the Employee Assistance Plan your company subscribes to), reporting you have scheduled and requesting the following information to bring to session:
Your Authorization #_____________________
Number of Sessions authorized :___________
Til soon, Thanks!
Celebrate. Cultivate. Care. Communicate.
|Release of Information Authorizaton||(As needed) Print, Fill in, Bring to Session|
|Parent/ Child Information Form||Parent, Please Print and Bring|
|Susan Bramlette, LMFT, Policy and Intake Form||Please Print, Sign, and Bring to First Session|
|Telehealth Informed Consent Form||(or FAX TO: 512.233.1021, email to|
|FEI Statement of Understanding||[email protected])|
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