INFORMED CONSENT, CONFIDENTIALITY INTAKE (E)

INFORMED CONSENT & PRACTICE POLICIES
CLIENT INFORMATION (Required)
Client Legal First Name*
Client Legal Last Name*
Date of Birth*
MM/DD/YYYY
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
TELEHEALTH EMERGENCY LOCATION (Required for Telehealth)
I am required by law to know your physical location during each telehealth session in case emergency services must be contacted.
ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name, Contact Phone & Relationship:*
INFORMED CONSENT FOR PSYCHOTHERAPY
Psychotherapy is a collaborative process between client and therapist that may involve discussing difficult emotions, experiences, relationships, and behaviors. Therapy may bring emotional discomfort including, but not limited to, sadness, anger, grief, anxiety, or frustration. While therapy often leads to meaningful benefits, no specific outcome can be guaranteed.
Services may include individual, couples, or family therapy, assessment, consultation, and psychoeducation.
You may discontinue therapy at any time.
I understand the nature, risks, and benefits of psychotherapy.
CONFIDENTIALITY & LIMITS OF CONFIDENTIALITY
All information shared in therapy is confidential except as required or permitted by law. Confidentiality may be broken without consent in the following circumstances:
- Risk of serious harm to yourself or others • Abuse or neglect of a child, elder, or dependent adult • Court orders or legal requirements • Professional consultation or supervision (without identifying information when possible) • Billing, payment, or legal defense matters
I understand the limits of confidentiality.

TELEHEALTH CONSENT
Telehealth involves the use of secure electronic platforms to provide therapy services when client and therapist are in different locations. I understand: Telehealth has risks such as technical interruptions. I am responsible for ensuring privacy at my location. I must provide my accurate physical location at each session. Telehealth is not appropriate for emergencies If a session is interrupted: The therapist will attempt to reconnect. If unable, I may be contacted by phone • Emergency services may be contacted if safety concerns arise
I consent to receive therapy via telehealth.
I understand that teletherapy services may only be provided when I am physically located in a state in which my therapist is licensed.

I confirm that I will only participate in teletherapy sessions while physically located in the following states:
Pennsylvania (PA), New Jersey (NJ), Delaware (DE), Georgia (GA), Oregon (OR), Arizona (AZ), Texas (TX), and Nevada (NV).

I agree to inform my therapist of my physical location at the start of each session and understand that services may be paused or terminated if I am located outside of these states.

I understand that providing inaccurate or incomplete information about my physical location may result in the immediate suspension of teletherapy services.
I acknowledge that I have read, understand, and agree to the teletherapy location requirements listed above.
FEES & PAYMENT POLICY
Private pay only. Insurance is not accepted. Payment is due prior to the start of session via the . The session will be cancelled if it is scheduled without payment.

Individual Therapy: 30 min - $55, 45 min - $75, 60 min - $100

Couples / Family Therapy: 30 min - $65, 45 min - $80, 60 min - $100
I understand and agree to the fee structure.
CANCELLATION & NO-SHOW POLICY
24+ hours notice: Full refund

Less than 24 hours: Non-refundable Missed sessions: No refund

Teletherapy sessions cannot be provided if a client is physically located outside of the states in which I am licensed.

If a session must be canceled or ended because the client is located in an unlicensed state and did not notify me at least 24 hours in advance, the session will be considered a late cancellation, and no refund will be issued.

Reschedules and cancellation are by email only. Please email sfarquharson@faithworkstherapy.com to request a different date, time or to cancel and receive a refund.
I understand the cancellation policy.

RELEASE OF INFORMATION (OPTIONAL)
I authorize FaithWorks Therapy, LLC to communicate with the following party: Name / Organization:
Please include the following: Name, Contact Information, Organization, Purpose
I decline to authorize any release of information at this time.
ELECTRONIC SIGNATURE
This form explains your therapy services, privacy rights, telehealth consent, fees, and cancellation policy.
By signing below, I confirm that I have read, understood, and voluntarily agree to the terms of therapy.
Client Electronic Signature:*

Clear
Date:*

MonthDayYear
Date

NOTICE OF PRIVACY PRACTICES

FaithWorks Therapy, LLC Shanae Farquharson, MS, MFT
This Notice describes how medical information about you may be used and disclosed and how you can
get access to this information. Please review it carefully.

Our Responsibilities

We are required by law to maintain the privacy and security of your Protected Health Information (PHI),
provide you with this notice, and notify you if a breach occurs.

How We May Use or Disclose Your PHI
• Treatment: To provide, coordinate, or manage your care.
• Payment: To collect payment for services provided.
• Health Care Operations: For quality improvement, supervision, audits, and administrative purposes.
• As Required by Law: Including reporting abuse, responding to court orders, or preventing serious harm.

Psychotherapy Notes
Psychotherapy notes are kept separate from your clinical record and are not disclosed without your written authorization, except as required by law.

Your Rights
You have the right to:
• Request access to or copies of your health records
• Request corrections or amendments
• Request confidential communications
• Request restrictions on certain uses or disclosures
• Receive an accounting of disclosures
• Receive a paper or electronic copy of this notice

Changes to This Notice
We reserve the right to change this notice and make the new provisions effective for all PHI we maintain.

Complaints
If you believe your privacy rights have been violated, you may file a complaint without fear of retaliation
by contacting:

Shanae Farquharson, MS, LMFT

Email: sfarquharson@faithworkstherapy.com
HIPAA NOTICE ACKNOWLEDGMENT
I acknowledge that I have received and reviewed the Notice of Privacy Practices describing how my Protected Health Information (PHI) may be used and disclosed. Please see attachment below.
I acknowledge receipt of the HIPAA Notice.

INTAKE QUESTIONNAIRE
What brings you to therapy at this time?*
What are you hoping to get out of therapy*
Have you been in therapy before? Anything helpful or unhelpful to know?*
Are you taking any psychiatric medications?*
Are you currently experiencing thoughts of harming yourself or others*
This question is asked of all clients.
This form is not a substitute for clinical assessment, which will occur during sessions.
Should be Empty:

INFORMED CONSENT & PRACTICE POLICIES

CLIENT INFORMATION (Required)

TELEHEALTH EMERGENCY LOCATION (Required for Telehealth)

INFORMED CONSENT FOR PSYCHOTHERAPY

CONFIDENTIALITY & LIMITS OF CONFIDENTIALITY

TELEHEALTH CONSENT

FEES & PAYMENT POLICY

CANCELLATION & NO-SHOW POLICY

RELEASE OF INFORMATION (OPTIONAL)

ELECTRONIC SIGNATURE

NOTICE OF PRIVACY PRACTICES

HIPAA NOTICE ACKNOWLEDGMENT

INTAKE QUESTIONNAIRE