FORMS

Required Forms

Please bring the appropriate forms for each person attending as well as your desired method of payment.

Clients cannot be seen until all appropriate forms are completed, signed and handed to your therapist for review. Because we do not want to waste your session time filling out paperwork, please make sure you bring the completed forms with you. Payment options include cash (correct change only), credit and check.

You will need:

HIPAA – Does not need to be copied or signed. It is to be read by each client and is available at all times on this website as well as in the office lobby.
Forms for Adults – One copy per adult.
Informed Consent for Adults – One copy total, signed by all participating adults/legal guardians.
Forms for Minors – One copy per minor. If there are no children/teens attending, this form is not needed.
Informed Consent for Minors – One copy total for all participating minors. Must be signed by all minors as well as all parents/legal guardians. If there are no children/teens attending, this form is not needed.
Parental Authorization for the Treatment of a Minor – One copy must be read and signed by both parents or guardians for all minors belonging to the parents. If there are no children/teens attending, this form is not needed.

Medicare Private Contract A provision in the Social Security Act permits Medicare beneficiaries and physicians (which includes mental health therapists) to contract privately outside of the Medicare program.

Collateral Support – One copy per person who is providing collateral support for the client, as prearranged by the client, family, and therapist, but is not the focus of treatment.
Telemental Health Consent – One copy per client who has prearranged with their therapist to utilize telemental health therapy.
COVID-19 Policy and Waiver – One copy total, signed by all participating adults/legal guardians.
Clients can not be seen until all appropriate forms are completed, signed and handed to your therapist for review. Because we do not want to waste your session time filling out paperwork, please make sure you bring the completed forms with you. Payment options include cash (correct change only), credit and check.

DISCLAIMER: By submitting any form via this web portal, you acknowledge and accept the risks associated with communicating your health information through an unencrypted email and electronic messaging system. Please know we do not track or sell your information. However, by continuing, you agree to hold Family Renewal Counseling and ArtisCollective harmless for unauthorized use, disclosure, or access of your protected health information sent electronically.

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