Patient Information

Contact Consent

Emergency Contact

Medical Information

Financially Responsible Party

(If different from patient)

Notice of Privacy Practices (HIPAA)

Your Health Information is confidential and protected by law. By signing below, you acknowledge receipt of our Notice of Privacy Practices, available upon request.

Authorization for Release of Information

I give (if applicable) permission to the Stress Management Center to share my psychological/psychiatric diagnoses or release information/records to the following agency/ person(s)

Party 1

Party 2

For Couples/Family Counseling

All participants must sign and date the document below to acknowledge their understanding of session confidentiality. For minors (under 18) in joint custody, both parents must sign

Consent for Treatment & Release

I have read and understood these forms. All of my questions have been answered. I give my consent to treatment and to speak with a clinician. I authorize my provider to discuss my care with other interoffice clinical providers as needed. The Stress Management Center may update

this policy at any time. By receiving services you agree to these terms