New Client Contact Info & Informed Consent Signature
Today's Date
*
Name
*
First Name
Last Name
Date of Birth
*
Gender
*
Pronouns
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Phone Number (if any)
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status / Name of partner
Name(s) and age(s) of children
Family of origin / Name(s) and age(s) of sibling(s)
Employer
Emergency Contact Name, relationship, and contact info
*
Primary Care Physician
*
Primary Care Clinic Name, Address & Phone number
*
Current medications
Informed Consent Signature Page
Please check to confirm each of the following:
*
RECEIPT OF NOTICE OF PRIVACY PRACTICES -- I have reviewed the Deeper Knowing, LLC 'Notice of Privacy Practices' (available on the Deeper Knowing, LLC website) and have had opportunity to discuss and ask questions about these practices with Katie Nissly, MSW, LICSW. I understand my rights to privacy as a client of Katie Nissly, MSW, LICSW, owner of Deeper Knowing, LLC.
*
RECEIPT OF PSYCHOTHERAPY PRACTICE AND BUSINESS POLICIES -- I have reviewed the Deeper Knowing, LLC 'Psychotherapy Practice and Business Policies' (available on the Deeper Knowing, LLC website) and have had opportunity to discuss and ask questions about said practice and policies with Katie Nissly, MSW, LICSW. I understand and agree to these policies.
*
CONSENT FOR TREATMENT -- I request that Katie Nissly, MSW, LICSW, owner of Deeper Knowing, LLC, provide therapeutic services to me and/or my minor child. [As a parent/guardian, I understand that I have the right to information concerning my minor child in therapy, except where otherwise stated by law. I also understand that this therapist believes in providing a minor child with a private environment in which to disclose himself/herself to facilitate therapy. I therefore give permission to this therapist to use her discretion, in accordance with professional ethics and state and federal laws and rules, in deciding what information revealed by my child is to be shared with me.]
*
CONSENT FOR BILLING AND PAYMENT -- I understand that Deeper Knowing, LLC, will NOT bill my insurance company on my behalf, and that I am fully responsible for all charges incurred. I authorize Deeper Knowing, LLC to charge my credit card, debit card, or HSA card for each appointment via the HIPAA compliant Ivy Pay app or to pay by cash or check.
*
CONSENT FOR ELECTRONIC MAIL COMMUNICATION -- I understand that email communication initiated by Katie Nissly, MSW, LICSW will be encrypted, but that if I initiate an email to Katie it will not be encrypted. Privacy of communication via email cannot be guaranteed because of the insecure nature of the technology. By signing below, I authorize Katie Nissly, MSW, LICSW to communicate with me regarding scheduling, billing, and otherwise related to my therapy via email.
CONSENT FOR CELL PHONE COMMUNICATION -- Please note that the privacy of communication via cell phone (including text) cannot be guaranteed because of the insecure nature of the technology. I understand that Katie Nissly, LICSW does not use encrypted technology for cell phone communication. By signing below, I authorize Katie Nissly, MSW, LICSW to communicate with me regarding scheduling, billing, and otherwise related to my therapy via cell phone.
Signature: I acknowledge that this form is true and accurate.
*
Submit
Should be Empty: