Mindful Steps PLLC – General Family Therapy Intake & Informed Consent

Mindful Steps PLLC – General Family Therapy Intake & Informed Consent

Complete the intake, confidentiality acknowledgments, and informed consent for voluntary outpatient family therapy.
Client & Family Intake
Primary Contact Full Name

First NameMiddle NameLast Name
Date of Birth

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

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Contact Method
Participating Family Members
Guardian Information for Minor Participants
Presenting Concerns & Therapy Goals
Presenting concerns

Other
If other, please describe
Goals for therapy
Section A: Family Therapy Confidentiality and Privacy Agreement
Mindful Steps PLLC follows HIPAA and applicable law; joint session information is heard by all participants and confidentiality cannot be guaranteed among family members; request all family members not share information outside therapy; mandated suspected abuse/neglect reporting, serious threats, valid legal mandates are exceptions; therapist will explain identified client/treatment unit, record access, private disclosures / secrets policy before start, acknowledgment is NOT a release to third parties.
I have read and understand the family therapy confidentiality agreement
Section B: Family Therapy Informed Consent
Therapy is a collaborative process aimed at supporting family functioning and treatment goals. Participation is voluntary, and possible risks include emotional discomfort, temporary relationship changes, and difficult discussions; possible benefits may include improved understanding, coping, and communication, but no outcome is guaranteed. Alternatives, questions, and withdrawal options will be discussed, and withdrawal is subject to applicable law.
I voluntarily consent to participate in family therapy
Section C: HIPAA Notice of Privacy Practices
The practice must separately provide the actual Notice of Privacy Practices. This acknowledgment is only receipt or access to that notice and is not a release of information to any third party.
I acknowledge receipt or access to the Notice of Privacy Practices
Section D: Telehealth Consent
Telehealth may involve a secure platform and possible technical, privacy, or communication risks. Please use a private setting, identify all people present at the session, and have a backup plan if the connection drops. Telehealth will only be used when clinically appropriate.
Do you consent to telehealth sessions?
Insurance Information for Each Participant

Upload a clear photo of the front and back of the insurance card for each participant. If several people use the same card, upload it again under each participant's name.
Front of Insurance Card

Cancelof
Back of Insurance Card

Cancelof
Section E: Financial Responsibility and Payment
Coverage is not guaranteed. Copays and deductibles may apply, and a separate fee and cancellation policy will be provided. No amounts are fabricated here; please refer to the practice policies for the current schedule of fees.
I acknowledge my financial responsibility under the separate practice policies
Section F: Individual Adult Consent and Minor Guardian Authorization
Each adult participant must sign separately, and each signature applies only to the person signing. For minors, the consent-authorized parent or legal guardian signs under applicable law.
I am signing for myself as an adult or am legally authorized to consent for the named minor
Minor participant name
Emergency notice: 911 and 988 are for emergencies and immediate crisis support.
Signer Information & Electronic Signature
Printed Name

First NameMiddle NameLast Name
Role
Electronic Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Mindful Steps PLLC – General Family Therapy Intake & Informed Consent

Client & Family Intake

Presenting Concerns & Therapy Goals

Section A: Family Therapy Confidentiality and Privacy Agreement

Section B: Family Therapy Informed Consent

Section C: HIPAA Notice of Privacy Practices

Section D: Telehealth Consent

Insurance Information for Each Participant

Section E: Financial Responsibility and Payment

Section F: Individual Adult Consent and Minor Guardian Authorization

Signer Information & Electronic Signature