Please read, print out and sign this form and bring it to your first appointment.
When I provide services to you, I will inevitably collect what the law calls protected health information (PHI) about you. I need this information to provide psychotherapy or other services to you. Generally, information about your status as a client or your therapy will not be given to anyone without your written permission. In certain circumstances I may share this information with others. Child abuse, molestation and neglect are required to be reported to the appropriate authorities, as is the threat of imminent harm to self or another. In most cases, however, you will need to sign an authorization in order for me to share your information with anyone.
The NOTICE OF PRIVACY PRACTICES form explains your rights in more detail. It explains how I will use your information, and under what circumstances I would share it. Please read it before you sign this consent. There is a permanent copy available in my lobby for you to read, or you may ask me for a copy. Your consent to my privacy practices as outlined in my NOTICE OF PRIVACY PRACTICES form is required for my professional services to be provided.
If you are concerned about release of your information, you have the right to ask me not to use or share some of your information. I am willing to discuss this with you at any time to answer questions or provide clarification.
Initial and date one of the following:
_________I want my primary care physician to receive information about my treatment.
_________I do not want my primary care physician to receive information about my treatment.
Signature of Client Date
Print name of Client