Forms

Client Information

Please complete the fields below.

First Name

Last Name

Primary Phone

Secondary phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Is client a minor?

Yes

Minor Client’s Legal Representative:

Primary Phone of Minor’s Legal Representative

Secondary phone of Minor’s Legal Representative

Emergency Contact

Relationship to Emergency Contact

Primary Phone of Emergency Contact

Secondary phone of Emergency Contact

Email address of Emergency Contact

Authorization for Electronic Communication

As a convenience to me, I authorize Cope Counseling & Coaching LLC to communicate with me regarding my treatment via electronic communications (email or text message) and to transmit my protected health information electronically as described below.

I understand there are risks inherent in the electronic transmission of information by email or text message:

– Such communication does not provide a completely secure means of communication.

– Any protected health information transmitted via electronic communications pursuant to this authorization may not be encrypted.

– Electronic transmission of information cannot be guaranteed to be secure or error-free.

– Data may be vulnerable to access by unauthorized third parties.

As such, Cope Counseling & Coaching LLC shall not have any responsibility or liability with respect to any error, omission, claim or loss arising from or in connection with the electronic communication of information by Cope Counseling & Coaching LLC to me.

Your treatment does not depend on consent. You have the right to terminate or amend this agreement at any time. The use of more secure communication methods, such as phone are available if you elect to not give consent to any of the forms of communication listed above.

I understand that Cope Counseling & Coaching LLC may transmit my protected health information electronically as described above unless and until I revoke or amend this authorization by submitting notice to Cope Counseling & Coaching LLC in writing. This authorization does not allow for electronic transmission of my protected health information to third parties, and I understand I must execute a separate authorization for my protected health information to be disclosed to third parties.

I authorize Text Communication:

Yes

Authorized Phone #

I authorize Email Communication:

Yes

Authorized Email (if different from the one given above)

I have read and agree to the Informed Consent Service Agreement.

I have read and agree to the Notice of Privacy Practices.

I have read and agree to the Informed Consent Checklist For Telehealth Services.

I have read the Parent/Adolescent Privacy Agreement. I agree to the items I have checked below.

Parent/Guardian Privacy Agreements-Detail

I will refrain from requesting detailed information about individual counseling sessions with my child. I understand that I will be provided with periodic updates about general progress, and/or may be asked to participate in therapy sessions as needed.

Although I know that in this state, I have the legal right to request written records/session notes since my child is a minor, I agree NOT to request these records in order to respect the confidentiality of my adolescent’s treatment.

I understand that I will be informed immediately about situations that could endanger my child. I know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment and may sometimes be made in confidential consultation with another provider/consultant.

E-Signature

By typing your name in the box below and submitting the form, you are stipulating that the answers you have provided in this form are complete and true to the best of your knowledge.

Your name

Client Information

Authorization for Electronic Communication

E-Signature

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