Psychotherapy Consents and Authorizations for Treatment

Alternative Therapies LLC

Consents and Disclosures for Treatment
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
HIPAA Privacy Authorization Form Release of Information **Authorization for Use or Disclosure of Protected Health Information(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)**

By signing the below, I am giving consent to Alternative Therapies LLC Michelle Palmer to speak with, obtain records, or discuss treatment, diagnoses, etc. for any reason unless otherwise noted below.
1. Effective Period**This authorization for release of information covers the period of healthcarefrom:

MonthDayYear
Begin Date
To

MonthDayYear
End Date
***OR***
**2. Extent of Authorization**

Other
3.
I am giving consent for Alternative Therapies LLC to speak with, obtain my medical records from, or discuss your treatment with the following individuals:
Primary Care Physician

First NameLast Name
Primary Care Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Psychiatrist

First NameLast Name
Psychiatrist Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Psychiatrist Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other: i.e. family member, friend, other business entity (court, lawyers, physician, school counselor, etc.)

First NameLast Name
Other Phone Number: i.e. family member, friend, other business entity (court, lawyers, physician, school counselor, etc.)
Please enter a valid phone number.Format: (000) 000-0000.
Other Address: i.e. family member, friend, other business entity (court, lawyers, physician, school counselor, etc.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature
Generalized Anxiety Disorder - 7

Generalized Anxiety Disorder 7-item (GAD-7) scale (Spitzer RL, Kroenke K, Williams JBW,Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med.2006;166:1092-1097.) Over the last 2 weeks, how often have you been bothered by the following problems?0= not at all sure, 1= several days, 2=over half the days, 3=nearly every day.
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
Over the last 2 weeks, how often have you been bothered by the following problems? 0= not at all sure 1= several days 2=over half the days 3=nearly every day
Add the score for each column Total Score =
How Many 0's+ How Many 1's + How Many 2's + How many 3's = total score
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
Signature
Patient Health Questionnaire

PHQ-9 Over the last 2 weeks how often have you been bothered by any of the following problems?0= Not at all, 1= Several days, 2= More than have the days, 3= Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling/staying asleep, oversleeping
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself, or that you are a failure or have let yourself or your family down
7. Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety, restless, or that you have been moving around a lot more than usual
8. Thoughts that you would be better off dead or hurting yourself in some way
Add the score for each column Total Score =
How Many 0's+ How Many 1's + How Many 2's + How many 3's = total score
If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Signature
Insurance Verification Authorization
By signing below, I agree to allow Alternative Therapies LLC, Michelle Palmer to submit insurance claim forms for reimbursement through my insurance company. I acknowledge that I am providing Alternative Therapies LLC Michelle Palmer with all of my current and correct insurance information at the time of the intake appointment and thereafter if my insurance information changes in any way.
Signature
Missed Appointment Agreement
By signing below, I hereby agree to the following statement: I acknowledge that I must notify the office of Alternative Therapies LLC, Michelle Palmer at least 24 hours prior to my appointment if I believe I will not be able to keep the appointment. I understand that in order to receive the most effective treatment, I must be compliant in keeping my appointments. If I do not notify the office at least 24 hours in advance, I am subject to a $50.00 charge at the discretion of the office of Alternative Therapies LLC Michelle Palmer.
Client Signature
Parent/Legal Guardian Signature (if under age 14)
Consent for Treatment with a Student Intern
Treatment with a Student Intern Informed Consent Form

By signing this form, I understand that my child, my family, or myself, will be receiving therapy services from a student intern who is under the supervision of Alternative Therapies, Michelle Palmer, LPC, NCC, ACS, CCS,CHAIS, CMHIMP, MH. All interns are supervised at Alternative Therapies,Michelle Palmer, LPC, NCC, ACS, CCS, CHAIS, CMHIMP, MH and the acting supervisor for their educational institution. Student interns are bound by the ethical guidelines of their profession and adhere to the guidelines specified by the Alternative Therapies servicesagreement, Telehealth Service Consent, Internship Supervision Agreement oftheir educational institution and Notice of Privacy Practices / HIPAA. Student interns have completed most masters level education from their educational institution in their field of study, have demonstrated core competencies and have been determined by their educational institution asready to apply his or her clinical skills to working with clients. Student interns receive intensive ongoing guidance, evaluation, and education in providing excellence in clinical skills to you and your family members. By working with astudent intern, each client receives the benefit of a clinically experienced supervision team assisting in assessment and treatment planning to address concerns in therapy. Student interns may provide counseling sessions in conjunction with a fully licensed clinician, and when deemed ready by Alternative Therapies, Michelle Palmer, LPC, NCC, ACS, CCS, CHAIS, CMHIMP, MH, will provide counseling sessions without a supervising clinician present. Sessions conducted by student interns may include recording of sessions, for use in supervision. Recordings may not be used for any other purposes than for use in supervision, are stored on a password protected device and are destroyed at the termination of therapy. Clients may terminate this agreement at any time, revokation of this agreement will require transfer to another provider as interns cannot be adequately supervised in cases that do not consent to recording. I, the client or his/her legal, custodial parent, or legal guardian,acknowledge that I am voluntarily authorizing treatment for myself or mychild/ward at Alternative Therapies, Michelle Palmer, LPC, NCC, ACS, CCS,CHAIS, CMHIMP, MH. I have been informed of the purpose of the treatment, the services which may be provided, and any attendant risks, consequences, and/or benefits.
Signature
Consent for Treatment and Disclosures Form
1.       I hereby consent to random urine drug screens at any time. My clinician has the discretion to determine if and when I will be tested.

2.      I am consenting to allow Alternative Therapies to contact me in the following ways: via telephone, via mail, via e-mail.

3.      I am consenting to Telehealth services which meet HIPAA privacy standards. The services I receive will become a part of my treatment record at Alternative Therapies. I understand the above and agree to receive services through telehealth.

4.      I am consenting to allow registered therapy dogs to be incorporated into my treatment. I agree that I am not allergic to dogs and will use proper handwashing protocol before and after I interact with the registered therapy dogs.

5.      I understand that at any time if it is a psychiatric emergency that I can contact the local hospital emergency room or PESS at 732-886-4474 for emergency assistance.

6.     I understand that at this time Alternative Therapies does not have an on-call emergency after-hours service, and I will contact 911 or local authorities if there is an emergency of any kind.
Signature
Should be Empty:

Alternative Therapies LLC

HIPAA Privacy Authorization Form Release of Information **Authorization for Use or Disclosure of Protected Health Information(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)**

Generalized Anxiety Disorder - 7

Patient Health Questionnaire

Insurance Verification Authorization

Missed Appointment Agreement

Consent for Treatment with a Student Intern

Consent for Treatment and Disclosures Form

HIPAA Privacy Authorization Form Release of Information Authorization for Use or Disclosure of Protected Health Information(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)