Prenatal Exposure to Controlled Substances. If a client admits prenatal exposure to controlled substances that are potentially harmful; • MINORS/GUARDIANSHIP: If a parent or legal guardian of non-emancipated minor clients request access to the client’s records; • COURT ORDER: If I am required to provide records or information by a court order. INSURANCE: By signing this agreement, I have your permission to provide protected health information to your insurance carrier, HMO, or billing office to procure payment for services rendered. Information that may be requested includes types of services, diagnosis, treatment plan, and description of impairment, progress of therapy, case notes, and summaries. Also, it is your responsibility to inform me of any changes to your insurance benefits as they occur. CLIENT SATISFACTION SURVEY: In an attempt to continue to provide the best therapeutic services I can, I ask your permission to send you a Client Satisfaction Survey for you to complete and send back to me at the completion of our work together. Please indicate whether you would agree to do this: ¨ Yes, I will complete and return this survey. ¨ No, I do not wish to participate in this survey. I welcome the opportunity to work with you on a personal level. I consider it an honor to enter into a therapeutic relationship with you and look forward to hearing about the work that gets done outside the therapy office, between our sessions. My (the client’s) signature(s) below indicates that I understand and agree with all statements in this Client-Therapist Agreement and that I consent to treatment with Xxxxxxxx Xxxxxxxxx, LMFT. (In the case that a minor child/teenager (under 18 years old) is receiving treatment, I consent for my child/teenager to obtain treatment.) Print Client Name Client Signature Date Signed Print Client Name Client Signature Date Signed Print Parent/Guardian Name (if client is under 18) Parent/Guardian Signature Date Signed I, the therapist, have discussed the issues above with the client (and/or his or her parent, guardian, or other representative). My observations of this person’s (and/or persons’) behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent. Xxxxxxxx Xxxxxxxxx, LMFT Print Therapist Name Therapist Signature Date Signed
Prenatal Exposure to Controlled Substances. (Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.)
Prenatal Exposure to Controlled Substances. Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. Minors/Guardianship Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.
Prenatal Exposure to Controlled Substances. If a client admits prenatal exposure to controlled substances that are potentially harmful MINORS/GUARDIANSHIP: If a parent or legal guardian of a non- emancipated minor client requests access to the client’s records COURT ORDER: If I am required to provide records or information by a court order Your signature below indicates that you understand and agree with all statements in this Client-Therapist Agreement and that you consent to treatment with XXXX XXXXXXX, LMFT. Print Client Name Client Signature Date Print Client Name Client Signature Date
