Sentirsi Counseling Client Intake & Consent Form

Sentirsi Counseling Client Intake & Consent Form

Please complete this form to provide your information and acknowledge key policies before starting counseling with Sentirsi Counseling, LLC.
Client Information

Please provide your contact and emergency details.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Name (if minor)

First NameLast Name
Custody Status (if applicable)
HIPAA Notice of Privacy Practices — Acknowledgment

Please review and acknowledge receipt of Sentirsi Counseling’s Notice of Privacy Practices.
Yes, I acknowledge
Client Initials*
Date*

MonthDayYear
Date
Informed Consent for Counseling

Please read the following information about your rights and responsibilities as a client.
Welcome to Sentirsi Counseling. My goal is to create a space where you feel understood, respected, and empowered. The information below outlines your rights, my responsibilities, and what you can expect from therapy.

PROVIDER INFORMATION
Clinician: Rachel Velishek, LPCC
Ohio License Number: E.1200015
Florida Telehealth Registration: TPMC3843
Practice: Sentirsi Counseling, LLC

NATURE OF COUNSELING
Therapy is a collaborative process. You may experience a range of emotions as we explore your story, strengths, and challenges. You are always encouraged to ask questions, slow down, or request support.

RISKS & BENEFITS
Potential benefits include increased insight, improved coping skills, emotional relief, stronger relationships, and personal growth.
Potential risks include temporary emotional discomfort, discussing difficult memories, or changes in relationships or routines.

YOUR RIGHTS AS A CLIENT
You have the right to be treated with dignity and respect, receive services free from discrimination, ask questions at any time, participate actively in your treatment, decline or withdraw from services, request referrals or second opinions, and access your records (with legal exceptions).

CONFIDENTIALITY & LIMITS
Your information is confidential except when required by law:
• Immediate danger to self
• Intent to harm others
• Abuse/neglect of minors, elderly adults, or individuals with disabilities
• Court‑ordered release of records

MANDATED REPORTING
As an LPCC, I am legally required to report suspected abuse or neglect of minors, elderly adults, or individuals with disabilities.

FEES, PAYMENT, & CANCELLATION
Session Fee:
Payment Method (choose one):
• HSA/FSA
• Other
Cancellation Policy:
No‑Show Policy:

USE OF DIAGNOSIS
If a diagnosis is clinically appropriate, I will discuss it with you openly and respectfully.

RECORD KEEPING
I maintain secure, HIPAA‑compliant records. You may request access at any time.
Session Fee (if known)
Therapy Follow-up Session Fee
Couples Session Fee
All sessions are paid at time of booking.
I confirm
Late Cancel Fee for Non-Emergency Cancellations
HSA/FSAOther
Telehealth Consent

Consent to participate in telehealth (video) sessions.
Client’s Usual Location for Telehealth Sessions*
Yes, I consent
Crisis & Emergency Instructions

Please review these instructions for crisis or emergency situations.
Sentirsi Counseling does not provide 24/7 crisis services.
If you are experiencing a crisis, emergency, or feel unsafe:
• Call or text 988
• Go to your nearest emergency room
• Or call 911
You may also contact someone you trust for immediate support.
Practice Policies

Please review key policies regarding communication, scheduling, and termination.
Psychotherapy notes are considered highly sensitive clinical documentation. These notes are kept separate from your general treatment record and are used solely by the therapist to support clinical thinking, treatment planning, and therapeutic reflection. Because of their sensitive nature, psychotherapy notes are not part of the standard medical record and are not released through routine requests for information. In accordance with HIPAA regulations and the Ohio Counselor, Social Worker, and Marriage & Family Therapist Board’s ethical guidelines, the release of psychotherapy notes is entirely at the discretion of the therapist. These notes will only be disclosed when legally required or when, in the therapist’s professional judgment, releasing them is clinically appropriate and does not compromise your privacy, safety, or therapeutic process. Requests for psychotherapy notes will be reviewed carefully, and alternative documentation (such as treatment summaries) may be provided when appropriate.
COMMUNICATION
Email and text may be used for scheduling only.
Clinical concerns must be addressed in session.
Social media contact is not permitted.

SCHEDULING
Typical Session Length:
Preferred Session Frequency (choose one):
• Weekly
• Biweekly
• Monthly
• As Needed

TERMINATION OF SERVICES
You may end therapy at any time. I may recommend termination or referral if your needs fall outside my scope, you require a higher level of care, or you are not benefiting from treatment.
Typical Session Length (minutes)
WeeklyBiweeklyMonthlyAs Needed
Client Rights & Responsibilities

Please review your rights and responsibilities as a client.
YOUR RIGHTS
• To be heard and respected
• To receive clear information
• To participate in treatment decisions
• To request accommodations

YOUR RESPONSIBILITIES
• Attend scheduled sessions
• Communicate openly
• Practice agreed‑upon skills
• Ask questions when unsure
Consent to Treat & Signatures

Please provide your consent and signature(s) below.
Client Name (Print)*

First NameLast Name
Yes, I consent
Client Signature*
Date*

MonthDayYear
Date
Parent/Guardian Signature (if minor)
Date

MonthDayYear
Date
Clinician Signature (for office use)

TELEHEALTH PLATFORM & COMMUNICATION STATEMENT

Sentirsi Counseling provides telehealth services through a HIPAA‑compliant, secure video platform to protect your privacy and confidentiality. All clinical sessions, therapeutic conversations, and treatment‑related communication occur only within this secure system. For communication outside the telehealth platform—such as scheduling, brief updates, or logistical coordination—I use Google Voice. Google Voice allows for protected communication but is not intended for clinical discussions. Email and text should be used only for administrative purposes. In accordance with HIPAA standards and the Ohio Counselor, Social Worker, and Marriage & Family Therapist Board’s ethical guidelines, sensitive clinical information will not be discussed through Google Voice, email, or text. Any therapeutic concerns, treatment questions, or personal disclosures must be addressed during your scheduled session or through the secure telehealth platform. I understand the difference between secure and non‑secure communication methods, and I consent to the use of a HIPAA‑compliant telehealth platform for clinical services and Google Voice for administrative communication only.
I understand and consent
Client Initials*
Date*

MonthDayYear
Date

Should be Empty:

Sentirsi Counseling Client Intake & Consent Form

Client Information

HIPAA Notice of Privacy Practices — Acknowledgment

Informed Consent for Counseling

Telehealth Consent

Crisis & Emergency Instructions

Practice Policies

Client Rights & Responsibilities

Consent to Treat & Signatures

TELEHEALTH PLATFORM & COMMUNICATION STATEMENT