Forms for Joyful Living Family Counseling

 

Intake Form

This form is required for all clients seeking counseling. It provides this therapist with general information about the client and their basic contact information.

Authorization to Release Confidential Information:

This form gives written permission for this therapist to exchange information, verbal or written, to the person of the clients’ designation. Examples may include, but are not limited to;

  • Previous therapist/counselor
  • Primary Care Provider (P.C.P.) or family doctor
  • Psychiatrist
  • Family member
  • Probation officer (P.O.)- required if treatment is mandated or paid for by P.O.
  • Department of Human Services (D.H.S.)- required if treatment is mandated or paid for by D.H.S.

**For adolescents between 15-18, this therapist does require that at least one release is signed for therapist to coordinate care with their primary care giver.

All releases expire one year from the date signed, unless the client gives permission for it to continue and may be revoked earlier at the clients’ request.

Consent to Treat a Minor- Custodial Guardian:

This form is required for clients that are 17 years or younger and are living with a custodial guardian rather than a parent.  This form should be signed by the custodial guardian to give therapist permission to treat the client.

Consent to Treat a Minor- Parent:

This form is required for clients that are 17 years or younger.  This form should be signed by both parents in order to give therapist permission to treat the client.

Heather Young Disclosure Statement:

This form is required for all clients seeking counseling.  It is a state mandated disclosure that gives the client information about this therapists qualifications and the clients’ rights within therapy.

Informed Consent:

This form is required for all clients seeking counseling.  This form gives the client a detailed description the following;

  • The therapeutic process
  • This therapist’s education and theoretical orientation
  • Fees and payment options
  • No show or late cancellation policy
  • Emergency protocol
  • Benefits and risks to therapy
  • Termination of therapy
  • Confidentiality

Notice of Privacy Practices:

This form does not need to be signed, but is for the clients’ personal records. This form gives you all the information needed to understand how your records are kept private and how to obtain access to your records.

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