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Client Information

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Bill To Contact

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Emergency Contact

First Name
Last Name

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )

Between 8 and 40 letters and numbers

Challenge Questions

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( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

Initial Interview, Assessment, and Possible Referral
Initial Interview, Assessment, and Possible Referral

The first appointment is an assessment interview in which your needs and expectations are discussed and a preliminary determination is made as to what services would be most beneficial to you. On occasion, this may require more than one interview. If the services provided by your therapist do not meet your needs, they will refer you to a more appropriate resource. Full payment is expected at the time of this service.
( Type Full Name )
Release of Information and Records
Release of Information and Records

Clients or their legal guardians often request that I obtain or provide information to other healthcare or mental health professionals, schools, insurance companies, and other relevant parties. For clients over 18, a signed authorization form must be filled out by the client to allow me to speak to anyone regarding their care, even parents. For children and teens, parents or legal guardians must fill out an authorization form before I can even acknowledge knowing the client.

Pursuant to HIPAA, I keep information about clients in a collection of professional records, known as your clinical record. You may receive a copy of your clinical record if requested in writing. Because these are clinical records, they are easily misinterpreted by untrained readers. For this reason, I recommend reviewing them together within a scheduled session or have them forwarded to another mental health professional so you can discuss the contents. There is an administrative fee of $35 for copying and mailing the record for release.
( Type Full Name )
Notice of Privacy Practices - Short Version
Notice of Privacy Practices - Short Version

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Our Commitment to Your Privacy

Our practice is dedicated to maintaining the privacy of your protected health information. I am required by law to do this and must provide you with this important information. The information presented here is a shorter version of the full, legally required Notice of Privacy Practices (NPP), which is located in the binder on the wall bin in the waiting area. Please refer to the NPP for more information. Also, feel free to take a personal copy from the binder. Since we cannot cover all possible situations, please talk with me about any questions or problems.

I will use the information about your health that I get from you or from others, mainly to provide you or your child with treatment, to arrange payment for services, or for other business activities, which are called in the law "healthcare operations". After you have read this NPP, I will ask you to sign a consent form to let me use and share this information. If you do not consent and sign, I cannot treat you or your child.

Of course, I will keep your health information private, but there are times when the laws require me to use or share it, such as the following:

1) When there is a serious threat to you or your child's health and/or safety, or the health and/or safety of another individual and/or the public. I will only share information with a person or organization who is able to help prevent or reduce the threat.
2) Some lawsuits and legal or court proceedings.
3) If a law enforcement official legally requires me to do so.
4) For workers compensation and similar benefit programs.

There are some other situations like these that do not happen very often. They are described in the long version of NPP.

Your Rights Regarding Your Health Information
1) You can ask me to communicate with you about your health and related issues in a particular way or at a certain place. For example, you can ask me to call you at home, and not at work, to schedule or cancel an appointment.
2) You have the right to ask me to limit what I tell certain individuals involved in you or your child's care, or in the payment of your care, such as family members and friends. While I do not have to agree to your request, if I do agree, I will keep our agreement except if it is against the law or in an emergency, or when the information is necessary to treat you or your child.
3) You have the right to a copy of this notice. If I change this NPP, I will post it in the waiting area and you can always get a copy of the NPP from me.
4) You have a right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with me and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care I provide to you in any way.
5) If you have any questions regarding this notice or our health information privacy policies, please let me know.

The effective date of this notice is July 1, 2012.

I have received and read the Notice of Privacy Policies.
( Type Full Name )
Social Media Policy
Social Media Policy

Individual therapists at Marietta Counseling and Roswell Counseling do not connect with clients on social media sites. This is to protect your privacy, confidentiality, and the integrity of the therapist/client relationship. Marietta Counseling and Roswell Counseling maintain a social media presence on some platforms (currently, Facebook and Pinterest). You are welcome to "like" these pages as we strive to provide educational material of interest to our clients. However, please be aware that if you "like" or "follow" us on social media sites, others may assume you are clients or have a professional relationship with Marietta Counseling and/or Roswell Counseling.
( Type Full Name )