New Patient Paperwork Packet

New Patient Paperwork Packet

Dr. Ross Family Counseling
Welcome to our practice! Please complete the following forms before your first appointment. This information helps us provide you with the best possible care.
Patient Information Form
Full Name*

First NameLast Name
Date*

MonthDayYear
Date
Gender*

MaleFemale
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Contact Method*

CallEmailsText
Emergency Contact*
Please enter a valid phone number.
Relationship*
Insurance Carrier*
Policy*
Primary Care Physician*
Referring Provider*
2. Consent to Treatment

I consent to receive counseling and therapy services at Dr. Ross Family Counseling. I understand the counseling process, possible risks, and that I may withdraw consent at any time. I also consent to telehealth sessions if applicable.
Signature*

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Date*

MonthDayYear
Date

3. HIPAA Acknowledgment

I acknowledge receipt of Dr. Ross Family Counseling’s Notice of Privacy Practices, which explains how my protected health information (PHI) may be used and disclosed, and outlines my rights under HIPAA.
Signature*

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Date*

MonthDayYear
Date
4. Financial Agreement & Office Policies
- I understand that I am responsible for all payments, including copays, deductibles, or self-pay fees.

- I agree to provide at least 24 hours’ notice for cancellations. Missed appointments may result in a fee.

- I understand billing and collection policies of this practice.
Signature*

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Date*

MonthDayYear
Date

5. Communication Consent

I consent to receive appointment reminders and general communications via phone, text, and/or email.
- Text reminders will not include sensitive PHI.

- Frequency: 1–2 reminders per appointment.

- Opt-Out: Reply STOP to unsubscribe at any time.
Signature*

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Date*

MonthDayYear
Date
6. Mental Health Intake Questionnaire
Primary Reason for Seeking Counseling*
Previous Counseling/Therapy*
If yes, when & where?*
Current Medications*
Medical Conditions*
Family/Social Background*

Safety Screening: Have you experienced thoughts of self-harm?

YesNO
7. Release of Information (Optional)
I authorize Dr. Ross Family Counseling to exchange information with the following (check all that apply)

Primary Care ProviderReferring PhysicianSchool / EmployerOther Specialist
Signature

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Date

MonthDayYear
Date
8. Patient Rights & Responsibilities
Your Rights:
- Receive respectful, confidential care.

- Access and request amendments to your records.

- Refuse or discontinue services at any time.

Your Responsibilities:
- Provide accurate and complete information.

- Attend scheduled sessions or give proper notice.

- Participate actively in your treatment.
9. Final Acknowledgments & Signatures

By signing below, I confirm that I have read, understood, and agree to all sections of this packet.
Patient/Guardian Signature

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Date

MonthDayYear
Date
Provider Signature (if required)

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Date

MonthDayYear
Date
Should be Empty:

Patient Information Form