Same-Day Service Intake & Consent Form

Same-Day Service Intake & Consent Form

Please select an available time slot for your appointment and provide your essential medical information.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code

Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship

Safety & Appropriateness Screening
1. Are you currently having thoughts of hurting yourself or others?
2. Are you experiencing a mental health crisis that makes it unsafe for you to wait for ongoing care?

This service is not appropriate for your needs today. If you are in crisis or thinking about suicide, please call or text 988 (the 988 Suicide & Crisis Lifeline) immediately, or go to the nearest emergency room. Support is available 24/7.

Service Description
- Same-day services are brief, solution-focused 50 minute sessions.
- These sessions are not crisis intervention. If you are in crisis, please call 988 or go to the nearest emergency room.
- Sessions may or may not transition into ongoing therapy. If ongoing therapy is recommended, we will help with referrals.

Informed Consent for Therapy
- I consent to receive therapy services through Soul Story Therapy – The Listening Room.
- I understand that this session is for short-term support, problem-solving, and planning, not emergency psychiatric care.
- I understand that my therapist may recommend ongoing therapy, referrals, or other resources.
- I understand that this service does not establish me as a long-term client unless I begin ongoing therapy.

Telehealth Consent (if applicable)
- If I choose a telehealth session, I must be physically located in Alabama (or another state where my therapist is licensed).
- I understand that while secure technology is used, confidentiality risks may occur.

Consent to Contact
- I consent to be contacted by phone, email, or text for scheduling and billing related to this appointment.

Optional Consent - Use of AI-Assisted Notetaking (Notetaker)
To improve accuracy and efficiency of documentation, your therapist may use an AI-assisted scribe tool (“Notetaker”) during or immediately after sessions.

What this means:
- Notetaker may transcribe portions of the session to assist in creating therapy notes.
- No audio or transcript is ever used for purposes outside clinical documentation.
- All information is processed through HIPAA-compliant, encrypted technology.
- Therapists review and finalize all notes personally before they become part of your record.
- You may decline participation at any time without affecting your care or access to services.
Please select a response below:
(If “Do not consent” is selected, therapists will complete documentation manually.)

Acknowledgments
- I consent to be contacted by phone, email, or text for scheduling and billing related to this appointment.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature

Safety & Appropriateness Screening