Informed Consent Form

Treatment consent, HIPAA acknowledgment, privacy practices, and financial policies for new patients.

Instructions: Review each consent item carefully with the client. All required consents must be acknowledged and a signature provided before the form can be completed.

Client Information

Client Name *

Date of Birth *

Date of Consent *

Required Consents

Consent to Treatment: I consent to receive psychological services from this practice. I understand that treatment will involve discussion of personal matters and that I am free to discontinue treatment at any time.

Informed Consent: I have been informed about the nature of psychological services, potential benefits and risks, and alternative treatments. I have had the opportunity to ask questions and discuss concerns.

Limits of Confidentiality: I understand that information shared in therapy is confidential with the following exceptions: risk of harm to self or others, suspected child/elder abuse, and court orders.

HIPAA Notice: I acknowledge receipt of the Notice of Privacy Practices as required by HIPAA.

Privacy Practices: I understand how my protected health information may be used and disclosed and have had the opportunity to review the privacy practices.

Financial Policy: I understand the fees for services, payment expectations, and my financial responsibility including any copays, deductibles, or self-pay amounts.

Cancellation Policy: I understand that I must provide at least 24-48 hours notice to cancel or reschedule an appointment to avoid being charged for the missed session.

Additional Consents (Optional)

Telehealth Services: I consent to participate in telehealth/video sessions when appropriate and understand the potential risks and benefits of remote services.

Emergency Contact: I authorize the provider to contact my designated emergency contact in case of a clinical emergency.

Care Coordination: I authorize the provider to coordinate care with my other healthcare providers (e.g., psychiatrist, primary care physician) as clinically indicated.

Signatures

Client Signature (Type Full Name) *

Date *

If client is a minor or requires a legal guardian:

Guardian/Parent Signature (Type Full Name)

Relationship to Client

Please complete all required consents and provide your signature to continue.