Here is a sample of the documents that new incoming clients are required to sign. To receive them via the Client Portal through Simple Practice, reach out via email, then you will be sent a request to create a portal account and complete these documents.

Document 1: Informed Consent for Mental Health Treatment,  Telehealth Consent, & Practice Policies

Forward Thinking Mental Wellness: 201-419-5308, info@think-nj.com

General Information

Hello and welcome to Forward Thinking Mental Wellness!  Beginning therapy is an exciting step in life and the purpose of this document is to outline information you need to make the decision to proceed with treatment, including policies, procedures, fees, and confidentiality. It is important that you have an understanding of the information below, and you can ask questions at any time to make sure you’re comfortable with this information.

Clearly defined rights and responsibilities held by each person in the therapeutic relationship are important to help our work together. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand.  There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you.  These rights and responsibilities are described in the following sections.

Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

Purpose, Risks, & Benefits

The purpose of psychotherapy is to assist individuals in coping with life's problems and resolving conflicts in order to thrive, achieved by increasing awareness, acceptance, coping abilities, and modifying behaviors.

Psychotherapy has both benefits and risks.  Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness because the process of psychotherapy often requires discussing the unpleasant aspects of your life.  However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems.  Outcomes vary, and no particular result can be guaranteed. Psychotherapy requires a very active effort on your part; in order to be most successful, you will have to work on things we discuss outside of sessions.

The Therapy Process

Our first few sessions will involve lots of questions as I get to know you and evaluate your needs.  Please try to be open and forthcoming with the information you share; the therapy process is non-judgmental and limiting information may hinder your progress.  We will discuss your treatment goals and create a plan to meet them.  It is important for you to have input in creating these goals and we will work together to establish priorities that are achievable and relevant.

Treatment may be brief or longer-term, depending on your needs and preferences. You may ask questions, discuss concerns, request a different approach, seek a referral, or end therapy at any time. If I believe treatment is not meeting your needs, payment is significantly overdue, or another circumstance makes continued treatment inappropriate, I will discuss the concern with you and, when clinically appropriate, support a transition or referral. Emergency or safety circumstances may require a different response.

Appointments & Cancellations

Sessions last approximately 45-53 minutes.  Please log in at the scheduled time, as we must end on time.  We may schedule on a weekly, biweekly, or monthly basis at a mutually agreed upon day and time.  You can reach out if you require additional sessions during a specific time of moderate crisis (although I am not always available and cannot be relied upon in an urgent situation) or may wish to adjust the frequency to more or less often as we progress. In the event of a medical or psychiatric emergency, or in any event in which you feel unsafe, please contact 911 or 988 or go to your nearest hospital’s Emergency Room. Do not rely on communicating with your therapist in the event of an emergency.

If you must miss a scheduled appointment, we can try our best to reschedule for another time during that week.  I try to accommodate changes as best as I can within reason, and sometimes I may also ask you to be flexible as well.  Cancellations made within 24 hours of the appointment will incur a fee of $100.  Insurance does not reimburse for cancellations and you are required to pay this out-of-pocket.

Fees & Insurance

The fee per session will be determined on a case-by-case basis before you begin your first session. Without insurance coverage, the typical rate for a self-pay, 53-minute session is $185. Many individuals are covered for therapy with a $10-50 copay. Sliding scales for self-pay, courtesy billing and/or “superbills” are available for out-of-network reimbursement, and “single case agreements” or “gap exceptions” may be available if your plan does not cover therapy with Forward Thinking Mental Wellness. Insurance participation varies by clinician and plan.  You are responsible for copayments, coinsurance, deductibles, uncovered services, and amounts the insurer does not pay. Out-of-network reimbursement varies by plan and is not guaranteed. You remain responsible for understanding your benefits and notifying the practice of coverage changes. Insurance companies may require a diagnosis and other information to process claims. Payment is generally due at the time of service unless a different arrangement is agreed to in writing. It is encouraged that you keep a credit card on file on our Client Portal for automatic payments. Zelle, Venmo, or checks are also accepted. Nikkie Rossetti is the point of contact for all insurance and financial matters, and she can be reached at info@think-nj.com.

Records

The practice maintains clinical and billing records as required by applicable law and professional standards. Records may include attendance, presenting concerns, history, diagnosis when applicable, treatment goals, progress, clinical notes, records received from other providers, and billing information. You may request access to or copies of your records in accordance with applicable law. Some records, including psychotherapy notes, may be subject to special rules or exceptions. The practice will explain any applicable process, limits, and fees.

Confidentiality

Session content and all relevant materials to your treatment are confidential, per the Health Insurance Portability and Accountability Act (HIPAA). Forward Thinking Mental Wellness requires your written authorization before disclosing information outside permitted uses, but there are legal and professional exceptions. The exact rules may depend on the type of record, who consented to treatment, the purpose of a disclosure, and applicable state or federal law. Exceptions to confidentiality may include legally required reports of suspected child abuse or neglect; reports involving certain vulnerable adults; certain serious and imminent safety risks; disclosures for treatment, payment, or health care operations as permitted by law; certain court orders or other legal processes; workers’ compensation matters; and other disclosures authorized or required by law. A subpoena is not necessarily the same as a court order, and the practice will respond to such requests in accordance with applicable law. The practice cannot promise that every consultation will be anonymous; when consultation is clinically appropriate, identifying information will be limited as required by law and professional standards. [See HIPAA Notice of Privacy Policies, to be signed.]

Parents & Minors

While privacy in therapy is crucial to successful progress, parental involvement can also be essential.  It is Forward Thinking Mental Wellness’s policy not to provide treatment to a child under age 13 unless the child agrees that information can be shared with parents when deemed clinically appropriate. For children 14 and older, an agreement between the client and the parents is required, allowing general information about treatment progress and attendance to be shared with a parent or guardian.  All other communication will require the child’s agreement, unless I feel there is a safety concern (see also above section on Confidentiality for exceptions), in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised.  [See Consent for Treatment of Minors Form, to be signed by both youth and parent(s).]

Communication, Boundaries, & Social Media

You may sign up for appointment reminders through the Client Portal, and you may also reach out to me to alert me of a cancellation or request to reschedule an appointment, or contact info@think-nj.com with any questions regarding your bill, account, etc. Communication through email or text message is very convenient, however it is not considered secure and your private information may be at risk of being viewed by third parties, as is other information stored on a cell phone or computer. You are welcome to communicate through those channels, however you do so with the understanding of that risk. Secured messaging is available through the Client Portal, although data breaches are still possible, even utilizing highly secured systems. 

All Forward Thinking Mental Wellness staff members strive to reply to all communication within 24-48 business hours. The practice operates in the state of New Jersey and all communications regarding time will be in Eastern Standard Time (EST). I am often not immediately available as I do not answer my phone when I am with clients or during my personal time.  I will make every attempt to inform you in advance of planned absences and, when possible, provide you with the name and phone number of a covering mental health professional.

If we run into each other outside of therapy, best-practice dictates that I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you. It is not, however, appropriate to engage in any lengthy discussions in public or outside of the virtual therapy meeting space.  

Further, due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients or their family members on any social networking site (Instagram, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

In the event of a medical or psychiatric emergency, or in any event in which you feel unsafe, please contact 911 or 988 or go to your nearest hospital’s Emergency Room. 

Telehealth

Telehealth means receiving services through electronic communications, such as secure video, telephone, or other approved technology. Telehealth is not identical to an in-person visit and may not be appropriate for every concern or circumstance.

Telehealth therapy appointments are considered to take place in the state where the client is located at the time. Forward Thinking Mental Wellness is licensed to operate in New Jersey with some clinicians also operating in PA, CT, or OR; please notify me in advance of any out-of-state travel plans that may impact our sessions. I am required to note your location at the start of each session so that I may assist however possible in any type of emergency.

There are potential risks, consequences, and benefits of telehealth. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs.

Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and other sensory observations, information, and experiences. When using telehealth for therapy services, potential risks include, but are not limited to: the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues (such as your gait and motor coordination, posture, some mannerisms or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene, body language, and more). Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally to the therapist.

CONSENT FOR TELEHEALTH CONSULTATION

  • I understand that my healthcare provider wishes me to engage in a telehealth consultation.

  • My healthcare provider explained to me how the video conferencing technology that will be used to conduct such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

  • I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

  • I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

  • I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE TELEHEALTH

Telehealth by SimplePractice, Doxy, or Google Meet are the technology services we likely will use to conduct telehealth videoconferencing appointments. By signing this document, I acknowledge:

  • Telehealth is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

  • Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor any telehealth service platform provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

  • The Telehealth by SimplePractice Service, Doxy, or Google Meet facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

  • I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service or other platform – or that such information is current, accurate or up-to-date. I will not rely on my healthcare provider to have any of this information in the Telehealth by SimplePractice Service or other platform.

  • At the start of each session, I will tell my clinician my current physical location and a callback number. I will notify the practice in advance of travel that may affect whether my clinician can legally provide services where I am located.

  • I will choose a private location when possible and use a secure device/network and inform the clinician if another person is present or can overhear the session. I will not share the session link with anyone who is not authorized to attend. I will not record any part of telehealth therapy.

  • If the connection fails, I will try to reconnect. If reconnection is not possible, I will follow the clinician’s agreed backup plan, such as a phone call.

Forward Thinking Mental Wellness does not utilize AI for any notetaking or similar purposes, and we do NOT record any therapy sessions. We do not permit recording of any kind by either the clinician or the client.

Emergencies

Teletherapy and routine communication are not emergency services. If you are in immediate danger or need urgent medical assistance, call 911 or go to the nearest emergency department. In the United States, call or text 988 for suicide or mental health crisis support. Your clinician may ask about your location and a callback number at the beginning of telehealth sessions so appropriate assistance can be arranged if needed.

Other Rights

You have the right to respectful care without unlawful discrimination, to ask about your clinician’s training and experience, to ask questions about treatment, to discuss concerns, to request a referral, and to end treatment. If you are dissatisfied, you may speak with your clinician or the practice owner, Nicole J. Rossetti, LCSW, LCADC, at info@think-nj.com. This email account is only viewed by the practice owner. Concerns will be taken seriously. You may also file a privacy complaint with the U.S. Department of Health and Human Services if you believe your privacy rights have been violated; the practice will not retaliate against you for filing a complaint.

BY ELECTRONICALLY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

EFFECTIVE JUNE 6, 2023

REVISED OCTOBER 15, 2026

Document 2: Contact & Emergency Contacts

Client Contact Information

Client legal full name: ______________________________________________________________________

Client preferred name: _____________________________________________________________________

Client date of birth: ________________________________________________________________________

Cell phone: _________________________________________________________________________________

Other phone: ______________________________________________________________________________

Email:  _____________________________________________________________________________________

Home address: _____________________________________________________________________________

Work address: ______________________________________________________________________________

Preferred Method of contact: ____ phone call ____text message ____ email

Is it OK to leave a voicemail message? ____ yes ____ no

Emergency Contacts

Please provide the information for 1-2 trusted contacts in case of an emergency.

Name: ____________________________________________________________________

Relationship to you: _________________________________________________________

Cell phone: ________________________________________________________________

Other contact method: _______________________________________________________

Name: ____________________________________________________________________

Relationship to you: _________________________________________________________

Cell phone: ________________________________________________________________

Other contact method: _______________________________________________________

Document 3: Financial Responsibility & Credit Card Authorization

Financial Responsibility

Thank you for choosing Forward Thinking Mental Wellness for care (“Provider”). We ask that you read and sign this form to acknowledge and agree to accept financial responsibility for services rendered by Provider to Client. 

I agree that I am legally responsible and agree to pay to the Provider for all fees, charges, and expenses incurred by the below Client or owed to Forward Thinking Mental Wellness in connection to Provider providing care to Client. I acknowledge and agree that I am responsible for the payment to Provider for any and all services rendered by Provider to Client. I have reviewed the fee and insurance information in the Informed Consent document.

Credit Card Authorization

Forward Thinking Mental Wellness holds a credit card (Visa, Mastercard, American Express, or Discover) on file to collect payments, cancellation fees, and any past due balances within 30 days of the date of service or less.  Payments should be automatically made on the date of service in most cases.  If you wish to establish an alternative method of payment (Venmo, Zelle, etc.), your credit card will be stored as a last resort in the event of an outstanding unpaid balance.  If a payment is rejected, a second attempt will be made to charge the card after 24 hours.

By your electronic signature of this form, you authorize charges to your credit card for services rendered. These charges will appear on your bank/credit card statement as “50 minute psychotherapy appointment”. The rate of therapy services is $185 per 50-minute session (unless you have a different agreement with Forward Thinking Mental Wellness). You have the right to request a paper copy of this document.

You certify that you are an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. You acknowledge that credit card transactions could be linked to Protected Health Information.

You understand that this authorization will remain in effect until you cancel it in writing, and you agree to notify Forward Thinking Mental Wellness in writing of any changes to your account information or termination of this authorization.

Client name: _______________________________________________________________

Client date of birth: __________________________________________________________

Credit Card Information

Card type:

  • Visa

  • Mastercard

  • American Express

  • Discover

  • Other:__________

  • FSA/HSA?

  • Debit

  • Credit

Cardholder name (as it appears on the card):_____________________________________

Card #: ___________________________________________________________________

Expiration date (mm/yy): _____________________________________________________

CCV (code on back of card): ___________________________________________________

Billing zip code: _____________________________________________________________

I, ____________________________, authorize Forward Thinking Mental Wellness to charge my credit or debit card above for agreed upon purchases.  I understand that my information will be stored on file for future transactions on my account.

____________________________________________ _________________________

Cardholder Signature Date

Document 4: Notice of Privacy Practices (HIPAA)

THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. Confidentiality

As a rule, I will disclose no information about you, or the fact that you are my client, without your written consent.  My formal Electronic Health Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis/progress, and any psychological testing reports.  As allowed by law, I may use or disclose records or information for treatment, payment, and health care operations purposes and require you to complete a HIPAA release of information form (attached) for any other disclosures.

II. Limits of Confidentiality

There are some important exceptions to this rule of confidentiality.  If you wish to receive mental health services from me, you must sign the attached form indicating that you understand and accept my policies about confidentiality and its limits.  We will discuss these issues now, but you may reopen the conversation at any time during our work together.

I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required:

· Emergency: If you are involved in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you.

· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by New Jersey State Law to report the matter immediately to 1-800-NJ-ABUSE.

· Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected, or exploited, I am required by New Jersey State Law to immediately make a report and provide relevant information to 1-800-NJ-ABUSE

· Health Oversight: New Jersey State Law requires that licensed mental health professionals report misconduct by a health care provider of their own profession.  I also reserve the right to report misconduct by healthcare providers of other professions.  By law, if you describe unprofessional conduct by another mental health provider of any profession, I am required to explain to you how to make such a report. If you are yourself a healthcare provider, I am required by law to report to your licensing board that you are in treatment with me if I believe your condition places the public at risk.  The State of New Jersey has the power, when necessary, to subpoena relevant records in investigating a complaint of provider incompetence or misconduct.

· Court Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information unless you provide written authorization or a judge issues a court order.  If I receive a subpoena for records or testimony, I will notify you so you can file a motion to block the subpoena. However, while awaiting the judge’s decision, I am required to place said records in a sealed envelope and provide them to the Clerk of Court.  Confidentiality may be broken in court cases related to allegations of child, adult, or elder abuse or neglect, or when you present a risk of harm to yourself or others, including direct threats of violence. Protections of privilege may not apply if I do an evaluation for a third party or where the evaluation is court-ordered.  You will be informed in advance if this is the case.

· Serious Threat to Health or Safety: Under New Jersey State Law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties.  These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization.  By my own policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety.

· Workers Compensation: If you file a worker’s compensation claim, I am required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.

· Records of Minors:  Individuals under the age of 18 require parental signatures for informed consent and HIPAA-related documents.  An exception to this is when minors are authorized to consent for their own health care and do so, the HIPAA Privacy Rule treats them as “individuals” who are able to exercise rights over their own protected health information (PHI).   Also, when parents have acceded to a confidentiality agreement between a minor and a health professional, the minor is considered an “individual” under the Rule.  Other circumstances may also apply, and we will discuss these in detail if I provide services to minors.  

Other uses and disclosures of information not covered by this notice or by the laws that apply to me will be made only with your written permission. [This sentence is now required under the HIPAA “Final Rule.”]

III. Patient’s Rights & Provider’s Duties

· Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you.  You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care.  If you ask me to disclose information to another party, you may request that I limit the information I disclose.  However, I am not required to agree to a restriction you request.  To request restrictions, you must make your request in writing, and tell me: 1) what information you want to limit; 2) whether you want to limit my use, disclosure, or both; and 3) to whom you want the limits to apply.

· Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me.  Upon your request, I will send your bills to another address.  You may also request that I contact you only at work, or that I do not leave voicemail messages.)  To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.

· Right to an Accounting of Disclosures: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in section III of this Notice).  On your written request, I will discuss with you the details of the accounting process

· Right to Inspect and Copy: In most cases, you have the right to inspect and copy your medical and billing records.  To do this, you must submit your request in writing. If you request a copy of the information, I may charge a fee for costs of copying and mailing.  I may deny your request to inspect and copy in some circumstances. I may refuse to provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative proceeding.

· Right to Amend: If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing, and submitted to me. In addition, you must provide a reason that supports your request. I may deny your request if you ask me to amend information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the medical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.

· Right to a copy of this notice: You have the right to a paper copy of this notice.  You may ask me to give you a copy of this notice at any time.

IV. Changes to This Notice

I reserve the right to change my policies and/or to change this notice, and to make the changed notice effective for medical information I already have about you as well as any information I receive in the future.  The notice will contain the effective date.  A new copy will be given to you or posted.  I will have copies of the current notice available on request.

V. Complaints

If you believe your privacy rights have been violated, you may file a complaint.  To do this, you must submit your request in writing to my office.  You may also send a written complaint to the U.S. Department of Health and Human Services.

Your electronic signature indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms.

“I have been provided a copy of Forward Thinking Mental Wellness Notice of Privacy Practices.  We have discussed these policies, and I understand that I may ask questions about them at any time in the future.  I consent to accept these policies as a condition of receiving mental health services.”

EFFECTIVE JUNE 6, 2023

Document 5: Release of Information (HIPAA)

Client’s Name:                                                                                           DOB:      /   /    

Complete this form for a specific disclosure or exchange of information. Use a separate authorization when needed for a different recipient or purpose. The practice should not rely on a broad “any/all information necessary for treatment” authorization without identifying the intended scope.

I,                                                          , authorize Forward Thinking Mental Wellness to:

  • Receive information from

  • Send information to

  • Speak to

Name (individual and/or agency):                                                                                                                     

City:                                                                                State:       Zip:            

Phone:                                       Email:                                      

The above information will be used for the following purposes:  

  • Appointment/attendance information

  • Treatment plan or progress summary

  • Diagnosis and relevant treatment information

  • Medication/medical information

  • Discharge summary

  • Billing/insurance information

  • Other (specify): ______________________________

I understand that signing this authorization is voluntary, and treatment or payment generally will not be conditioned on signing unless a legally permitted exception applies. I may revoke this authorization in writing at any time, except to the extent action has already been taken in reliance on it. I may receive a copy of this authorization. Information disclosed to a recipient may no longer be protected by HIPAA if the recipient is not subject to HIPAA or another applicable privacy law. Additional protections may apply to substance-use-disorder records and other specially protected information.

The practice should have counsel verify the required wording, expiration rules, revocation language, any required redisclosure notice, and whether a separate authorization is needed for psychotherapy notes or Part 2 records.

If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.

Document 6: External Referral Waiver/Release of Liability

At Forward Thinking Mental Wellness, we understand that the challenges you face are complex.  We want to help as much as possible, which sometimes includes referring you to a facility, psychiatrist, doctor, or other type of provider that is outside of our organization. While we strive to provide the highest quality referrals to providers with excellent feedback, we do not have any direct affiliations with outside service providers.  Therefore, you must agree to hold Forward Thinking Mental Wellness and all of its direct affiliates harmless in the event that you utilize a referral and are unhappy with the services rendered.  If any legal action is taken by you or a representative of you against another provider, Forward Thinking Mental Wellness and it’s employees claim no responsibility for the actions that lead to the litigation.

EFFECTIVE JUNE 6, 2023

Document 7: Treatment of Minors (optional)

The involvement of children and adolescents in therapy can be highly beneficial to their overall development.  Very often, it is best to see them with parents and other family members; sometimes, they are best seen alone.  I will assess which might be best for your child and make recommendations to you.  Obviously the support of all the child’s caregivers is essential, as well as their understanding of the basic procedures involved in counseling children.

The general goal of involving children in therapy is to foster their development at all levels.  At times, it may seem that a specific behavior is needed, such as to get the child to obey or reveal certain information.  Although those objectives may be part of overall development, they may not be the best goals for therapy.  Again, I will evaluate and discuss these goals with you.

Because my role is that of the child’s helper, I will not become involved in legal disputes or other official proceedings unless compelled to do so by a court of law.  Matters involving custody and mediation are best handled by another professional who is specially trained in those areas rather than by the child’s therapist.

The issue of confidentiality is critical in treating children.  When children are seen with adults, what is discussed is known to those present and should be kept confidential except by mutual agreement. Children seen in individual sessions (except under certain conditions) are not legally entitled to confidentiality (also called privilege); their parents have this right.  However, unless children feel they have some privacy in speaking with a therapist, the benefits of therapy may be lost.  Therefore, it is necessary to work out an arrangement in which children feel that their privacy is generally being respected, at the same time that parents have access to critical information.  This agreement must have the understanding and approval of the parents or other responsible adults and of the child in therapy. 

·     Confidentiality and privilege are limited in cases involving child abuse, neglect, molestation, or danger to self or others.  In these cases, the therapist is required to make an official report to the appropriate agency and will attempt to involve parents as much as possible.

·     Minors may independently enter into therapy and claim the privilege of confidentiality in cases involving abuse or severe neglect, molestation, pregnancy, or communicable diseases, and when they are on active military duty, married, or officially emancipated.  They may seek therapy independently for substance abuse, danger to self or others, or a mental disorder, but parents must be involved unless doing so would harm the child. (These circumstances may vary from state to state, and the specific laws of each state must be followed.)

 ·     Any evaluation, treatment, or reports ordered by, or done for submission to a third party such as a court or a school is not entirely confidential and will be shared with that agency with your specific written permission. Please also note that I do not have control over information once it is released to a third party.                                     

I, (name)  ____________________________________                            (relationship to child)      

& I, (name)  ____________________________________                            (relationship to child)               

agree that my/our child (name)  _____________________ should have privacy in his/her/their therapy sessions, and I agree to allow this privacy except in extreme situations, which I will discuss with the therapist.  At the same time, except under unusual circumstances, I understand that I have a legal right to obtain this information.

I will do my best to ensure that therapy sessions are attended and will not inquire about the content of sessions.  If my child prefers not to volunteer information about the sessions, I will respect his/her/their right not to disclose details.  Basically, unless my child has been abused or is/are a clear danger to self or others, the therapist will normally tell me only the following:

·    whether sessions are attended

·    whether or not my child is/children are generally participating

·    whether or not progress is generally being made

The normal procedure for discussing issues that are in my child’s therapy will be joint sessions including my child, the therapist, and me, and perhaps other appropriate adults.  If I believe there are significant health or safety issues that I need to know about, I will contact the therapist and attempt to arrange a session with my child present.  Similarly, when the therapist determines that there are significant issues that should be discussed with parents, every effort will be made to schedule a session involving the parents and the child.  I understand that if information becomes known to the therapist and has a significant bearing on the child’s/children’s well-being, the therapist will work with the person providing the information to ensure that both parents are aware of it. In other words, the therapist will not divulge secrets except as mandated by law, but may encourage the individual who has the information to disclose it for therapy to continue effectively.

EFFECTIVE JUNE 6, 2023 

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