WP E-Signature by Approve Me - Sign Documents Using WordPress -

Consent for Services

I hereby request and consent to participate in outpatient counseling/psychotherapy sessions with a Licensed Clinical Social Worker or other Licensed mental health practitioner. I understand my therapist may change during the course of treatment for various reasons and this consent is for any Licensed therapist under the Blue Moon Senior Counseling organization. The frequency, type and location of sessions will be decided between me and my therapist. I understand there is an expectation I will benefit from psychotherapy but there is no guarantee this will occur. I understand at some times I may feel conflicted, as the process can sometimes be uncomfortable.

I understand information disclosed by me during the course of my therapy is generally confidential. However, there are exceptions to confidentiality, including but not limited to reporting child, elder and vulnerable adult abuse; if I pose an imminent danger to myself or others, am having a medical emergency, express threats of violence toward an ascertainable victim; and/or if there is a subpoena for records by a court of law. I understand my therapist may need to contact my Emergency Contact and/or appropriate authorities in case of an emergency.

For telehealth sessions I understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a therapist and a client who are located in two different locations and possibly two different states. I understand there are risks and consequences from these services including but not limited to, the possibility, despite reasonable efforts by my therapist, that the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons and/or limited ability to respond to emergencies.

I understand that there will be no recording of any sessions by either party. All information disclosed within sessions and records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved, it may be determined that outpatient and/or telehealth services are not appropriate and a higher level of care is required.

I have a right to access my medical information and copies of my medical records via written request in accordance with HIPAA privacy rules and applicable state law.

Assignment of Benefits

By signing this form, I authorize the release of necessary information about my case to my insurance carriers to process insurance claims for services rendered. I assign benefits to Blue Moon Senior Counseling for any eligible payments. This is a direct assignment of the rights and benefits under my insurance policy. My signature on this form serves as signature on file and may be revoked in writing at any time. I understand that I may be billed for services not covered by my insurance including deductibles and copayments as required by law. With my consent, Blue Moon Senior Counseling may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO).

I have been provided a Notice of Privacy Practices and know that Privacy Practices can be found under ‘forms’ section on website: www.bluemoonseniorcounseling.com.

I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment. I have read, understand and consent to the information provided above.

Emergency Contact Person’s Name and Phone Number (optional):

I consent to Blue Moon Senior Counseling being able to leave voice and/or text messages for me at the following number:

Patient Info:

Date Signed:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

April 3, 2020 7:58 pm PDT

Consent for Services Uploaded by Melanie Donohue - new@bluemoonseniorcounseling.com IP 47.152.80.109

May 26, 2020 11:28 am PDT