BASIC CLIENT INFORMATION

INSURANCE AND PAYMENT INFORMATION

PRESENTING CONCERNS

MENTAL HEALTH SYMPTONS CHECKLIST

MEDICAL & PSYCHIATRIC HISTORY

FAMILY & SOCIAL HISTORY

CONSENT & POLICIES

Informed Consent for Treatment

I voluntarily agree to participate in mental health services provided by Felicia Walker-Williams, LCSW. The purpose of therapy is to help address emotional, psychological, behavioral, or relational concerns.

Therapy may include discussing difficult experiences, emotions, and behaviors. While many clients benefit from therapy, there are no guarantees regarding specific outcomes.

I understand that:

• I have the right to ask questions about my treatment at any time.

• I may stop treatment at any time.

• Therapy works best with active participation and honesty.

• Sessions typically last 45–60 minutes unless otherwise discussed.

By signing below, I acknowledge that I understand the nature of therapy and consent to treatment.

HIPPA Privacy Acknowledgement

I acknowledge that I have received or have been given access to the Notice of Privacy Practices, which explains how my protected health information (PHI) may be used and disclosed.

I understand that my therapist is required by law to protect the privacy of my health information and provide me with information about my rights regarding my records.

By signing this form, I confirm that I have been informed of these policies.

Telehealth Consent (If Applicable)

Telehealth services allow therapy sessions to be conducted through secure video or online platforms.

I understand that telehealth may involve the following risks:

• Technology failures or interruptions

• Potential privacy risks if using unsecured internet connections

• Limitations compared to in-person therapy

I agree to participate in telehealth sessions when appropriate and understand I may request in-person sessions when available.

I also agree to:

• Participate in sessions in a private and safe environment

• Use a secure internet connection whenever possible

Limits of Confidentiality

All information shared during therapy is confidential. However, there are certain legal exceptions where confidentiality may be broken.

Confidentiality may be limited if:

• There is suspected abuse or neglect of a child, elder, or dependent adult

• There is serious risk of harm to yourself

• There is serious risk of harm to another person

• Records are requested by court order

In these situations, the therapist is legally required to take steps to ensure safety.

Cancellation & No-Show Policy

Your appointment time is reserved specifically for you.

• 24-hour notice is required to cancel or reschedule an appointment.

• Appointments canceled with less than 24 hours notice may be subject to a late cancellation fee.

• Missed appointments (no-shows) may also be charged a fee.

Insurance companies typically do not cover missed appointment fees, and the client is responsible for payment.

Electronic Signature Agreement

By signing electronically, I acknowledge that my electronic signature is legally binding and has the same effect as a handwritten signature.