Consent to Collect Personal Health Information

Consent to Collect Personal Health Information

Individual Psychotherapy
At Mindfulness with Mae, we collect your Personal Health Information during the therapeutic process to help determine the types of treatment that are most appropriate for you.

Personal Health Informaiton may include:
- Your name, address and phone number
- Your physical and mental health
- Your personal health history
- Issues that you are experiencing
Name

First Name Last Name
Date of Birth
Email
example@example.com
Have you ever participated in psychotherapy before?
What current challenges are you facing?

Grief/Loss Relationship Issues Substance Abuse Stress Depression, Anxiety Personality Disorder ADD/ADHD Other
Do you have a history of suicide or suicidal ideation?

Yes No
If yes, when was the last attempt?

1-3 months ago 3-6 months ago 6-12 months ago Over 1 year ago
Is there anything else you believe we should know?
I, First Name Last Name understand the potential risks associated with participating in psychotherapy and agree to take part in private, individual session(s).
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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