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, signing for their child, to the first session.
One parent is asked to attend the first session with your minor child.
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 :___________
End Date:_______________
Copay=__________________________________
Til soon, Thanks, Susan
Celebrate. Cultivate. Care. Communicate
Use your Gmail, MSN, Apple password or create a personal passphrase
Consent to Release and/or Receive Confidential Information
Limitations of Confidentiality When Working with Couples or Families
