Intake Forms

Informed Consent

Contact Information*
Agreement to Provide Psychotherapy Services Athena Counselor, LCSW 314 282 7275 your-email-address@insession.io Address: 99 Bank St, Suite 5B NY, NY 10014
Name*
First Last
Phone*
Email
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
CONFIDENTIALITY*
All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where required by law. For clients engaged in couples therapy both partners must give written permission, except where required by law.
DISCLOSURE REQUIRED BY LAW*
The circumstances where such disclosures are required by law include the following: when reasonable suspicion of child, dependent, or elder abuse or neglect; when a client presents a danger to self or others.; when ordered by a judge.
LITIGATION LIMITATION*
Due to the nature of the therapeutic process and the involvement of confidential disclosures, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.) neither you, nor your attorney, nor anyone else acting on your behalf will call upon Athena Counselor to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested. If you become involved in a divorce or custody dispute, understand that you should hire a different mental health professional as Athena Counselor’s statements will be seen as biased in your favor.
CONSULTATION*
Athena Counselor consults regularly with other mental health professionals regarding clients; however, clients’ names and other identifying information are never mentioned. The client’s identity remains completely anonymous and confidential.
YOUR RIGHTS*
As a client, you have the right to terminate treatment at any time and request appropriate referrals. Athena Counselor will assist you in finding someone qualified and will consult with said professional with your written consent. You have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances, or when Athena Counselor assesses that releasing such information might be harmful in any way. In such a case, she will provide the records to an appropriate and legitimate mental health professional of your choice. Note that in cases where clients are participating in couples therapy sessions any release of information (including release of records to the clients themselves) will require written consent from both participating clients.
PAYMENT*
PAYMENT: Clients are expected to pay the standard fees listed for individual session and couples session at the time of the session. Telephone sessions, professional letters, etc. may be charged at the same rate. Cash and accepted as well as credit cards with an additional 3 percent service fee.
Payment Acknowledgment*
Type your fullname
INSURANCE*
Please note that Athena Counselor does not accept insurance. Upon request, she will provide you with a receipt to submit to your insurance company for possible reimbursement. Not all issues that are the focus of psychotherapy are reimbursed by insurance companies, nor do all companies reimburse. It is your responsibility to verify the specifics of your coverage.
APPOINTMENTS*
Traditionally, a “one hour” therapy session is considered to be approximately 50 minutes of “face to face” contact with the client(s). The remaining 10 minutes is used for the therapist to review records and complete notes. The length and frequency of therapy sessions depend on many factors which may be discussed during your initial session.
CANCELLATIONS/MISSED SESSIONS*
If you need to cancel an appointment, you must give at least 24-hour notice. You will be charged the full session fee if less than 24-hour notice is given, or if you do not show up for the scheduled appointment. In the case of any unpaid charges, you will not be able to schedule any appointments with Athena Counselor. If you fail to attend two consecutive appointments or cancel/no-show an excessive number of appointments, Athena Counselor may terminate your case due to noncompliance with treatment.
THE PROCESS OF THERAPY AND EVALUATION*
Participation in therapy can result in a number of benefits to you, including improving resolution of the specific concerns that led you to seek therapy. Working toward these benefits requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order transform thoughts, feelings, and/or behaviors. During therapy, remembering unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, anxiety, depression, insomnia, etc. Athena Counselor may challenge some of your assumptions or perceptions or propose a different way of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, disappointed, peaceful or relieved. Attempting  to resolve issues that brought you into therapy may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change may also  be easy and swift, but often it will be slow and perhaps frustrating at times. There is no guarantee that therapy will yield intended results.
TERMINATION*
After the first several meetings, Athena Counselor will assess if she can be of benefit to you. She does not accept clients who, in her opinion, she cannot help. In such a case, she will give you a number of referrals. If at any point during therapy, Athena Counselor assesses that she is not effective in helping you reach the therapeutic goals, she is obligated to discuss it with you and, if appropriate, to terminate treatment. In such a case, she would provide referrals. If you request and authorize it in writing, Athena Counselor will talk to the psychotherapist of your choice in order to help with the transition. You have the right to terminate therapy at any time.
I UNDERSTAND THE ABOVE TERMINATION*
- I Understand
DUAL RELATIONSHIP/SOCIAL MEDIA*
Therapy never involves sexual or business relationships or any other dual relationships that impair Athena Counselor’s objectivity, clinical judgment, therapeutic effectiveness, or that may be exploitative in nature.  Per the AAMFT and ACA Code of Ethics and best practices of psychotherapy, Athena Counselor does not establish social media relationships of any kind with clients. This is considered a dual relationship and can have an adverse effect on the course of therapy. This includes LinkedIn, Facebook, Instagram and any other such platforms. Athena Counselor will not accept friend requests from active or past clients.
AVAILABILITY/CONACT*
Athena Counselor is in the office most days during normal business hours and can be contacted. She is not available on a crisis basis, nor is she available during evening, weekend or vacation times, unless agreed upon. A message can always be left on her voicemail and she will make every effort to return calls within 24 business hours. If for some reason she is not available for an extended time, urgent contact information will be left on her voicemail outgoing message. Contact by text and email should be reserved exclusively for appointments as confidentiality cannot be guaranteed. Therapeutic questions cannot be answered by text or email and should be addressed in session or during scheduled calls.
I have read the above Agreement and Policies and General Information carefully. I understand them and agree to comply with them. I consent to treatment.*
- I Agree
Client Signature*
Type your full name
Date*
Date Format: MM slash DD slash YYYY

Informed Consent For Online Therapy

Contact Information*
INFORMED CONSENT ADDENDUM FOR ONLINE THERAPY Athena Counselor, LCSW 314 282 7275 your-email-address@insession.io Address: 99 Bank St, Suite 5B NY, NY 10014
Name*
First Last
Phone*
Email
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Terms*
This form is designed to allow you to give informed consent for the use of video technology for online therapy. Read it thoroughly for understanding and ensure that all of your questions are answered before signing to give consent. This is to be used in conjunction with, but does not replace, the Informed Consent document that is required of all clients prior to starting therapy services. I understand that therapy conducted online is technical in nature and that problems may occasionally occur with internet connectivity. Difficulties with hardware, software, equipment, and/or services supplied by a 3rd party may result in service interruptions. Any problems with internet availability or connectivity are outside the control of the therapist and the therapist makes no guarantee that such services will be available or work as expected. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video conferencing, I agree to call my therapist back at (407)951-3820. I AGREE TO TAKE FULL RESPONSIBILITY FOR THE SECURITY OF ANY COMMUNICATIONS OR TREATMENT ON MY OWN COMPUTER AND IN MY OWN PHYSICAL LOCATION. I understand I am solely responsible for maintaining the strict confidentiality of my user ID and password and not allow another person to use my user ID to access the Services. I also understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation. I understand that there will be no recording of any of the online session and that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law.
Consent to Treatment: I, voluntarily agree to receive online therapy services for an assessment, continued care, treatment, or other services and authorize Athena Counselor, LCSW to provide such care, treatment, or services as are considered necessary and advisable. I understand and agree that I will participate in the planning of my care, treatment, or services and that I may withdraw consent for such care, treatment, or services that I receive through Athena Counselor, LCSW at any time. By signing this Informed Consent, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.*
- I Agree
Client Signature*
Type your full name
Date*
Date Format: MM slash DD slash YYYY

Notice of Privacy Practices - HIPAA

Contact Information*
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. Athena Counselor, LCSW 314 282 7275 your-email-address@insession.io Address: 99 Bank St, Suite 5B NY, NY 10014
Name*
First Last
Phone*
Email
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Confidentially and Privacy*
Confidentially and privacy are cornerstones of the counseling profession. Communication with me, as well as documentation of your treatment, generally will be kept confidential and will not be released to others without your written authorization. One of the purposes of the Notice of Privacy Practices is to inform and educate you about the fact that there are exceptions to the general rule of confidentiality. Many of these exceptions have existed for years; others are the result of laws and regulations being passed by the State legislature and by the federal government. These laws and regulations are essentially statements of public policy. My office policies and procedures, as well as the ethical standards of the American Mental Health Counselors Association, are intended to shape my practice so that privacy and confidentiality are maintained, consistent with State law and the federal “Privacy Rule”.
Confidentially and Privacy Continued*
1. Privacy Officer: I, Colette J. Fehr, am the Privacy Officer for this practice. I am the one responsible for developing and implementing these policies and procedures. 2. Contact Person: I, Colette J. Fehr, am the contact person for this practice. If a client needs or desires further information about the Notice of Privacy Practices, or if a client has a complaint regarding these policies or procedures or compliance with them, I am the person who should be contacted. 3. I will maintain documentation of all consents, authorizations, Notice of Privacy Practices, office policies and procedures, trainings, and client requests for records or for amendments to records. I will also document complaints received and their disposition. 4. In the event I should acquire an employee (clerical/administrative), I will train all employees regarding the importance of privacy and confidentiality. 5. Conversations regarding confidential material or information will take place in an area and in a manner that these conversations will not easily be overheard. 6. Client records will be kept in locked file cabinets in my office. Client records will not be left in places where others are able to see the contents. I will take steps to assure that my employees who need to access them on my behalf or on the client’s behalf only have access by me or, with my permission, client records. 7. Computer and fax machines will be placed appropriately so that access is limited to office personnel and that confidential information transmitted or received is not seen by others. Information and records concerning a client may be disclosed as described in the Notice of Privacy Practices and in accordance with applicable law or regulation. 8. Generally, I will obtain a written authorization from the client before releasing information to third parties for a purpose other than treatment payment and health care operations, unless disclosure is required by law or permitted by law. 9. If mental health records are subpoenaed by an adverse party I will assert the psychotherapist/client privilege (Florida Statute, Chapter 90.503) on behalf of the client and will thereafter, according to the wishes of the client and the client’s attorney, unless I am ordered by a judge (court order) or other lawful authority to release records or portions thereof. 10. I will keep all client records for at least seven years from the date of the last treatment. With respect to the records of a minor, I will keep those records for at least seven years or until the client is twenty-one years of age, whichever is longer. Thereafter, I may destroy client records. When records are destroyed, they will be destroyed in a manner that protects client privacy and confidentiality. 11. I will attempt to find out from the client whether they have an objection to receiving correspondence from me or my employees at their residence and how I am permitted to contact them. The purpose of this correspondence would be to change appointment times or dates, discuss matters related to treatment, invoices or claim forms. 12. If I share protected health information about a client with third party business associates as part of my health care operations (e.g., billing or transcription service), I will have a written contract with that business that contains terms that will protect the privacy of the client’s protected health information. 13. My duty to confidentiality and the psychotherapist-patient privilege survive the death of a patient (client); and therefore, I will remain bound by my duty unless released by the client’s legal representative. 14. You have the right to request restrictions on certain uses and disclosures of protected health information about the client, such as those necessary to carry out treatment, payment or health care operations. I am not required to agree to your requested restriction. If I do agree, I will maintain a written record of the agreed upon restrictions. 15. You have the right to inspect and copy protected health information about the client by making a specific request to do so in writing. This right to inspect and copy is not absolute – in other words, I am permitted to deny access for specific reasons. For instance, you do not have this right of access with respect to my “psychotherapy notes”. The term “psychotherapy notes” means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversations during a private counseling session, a group counseling session, or a family counseling session and that are separated from the rest of the client’s medical/mental health records. The term “psychotherapy notes” excludes medication prescription and monitoring (not appropriate to my practice), counseling session start and stop times, the modalities and frequencies of treatment furnished, result of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. 16. You have the right to amend protected health information in records by making a request to do so in writing that provides a reason to support the requested amendment for specific reasons. You have the right, subject to limitations, to provide me with a written addendum with respect to any item or statement in your records that you believe to be incorrect or incomplete and have the addendum become part of the client’s record. 17. You have the right to receive an accounting from me of the disclosures of protected health information made by me in the past six years prior to the date on which the accounting is requested. As with other rights, this right is not absolute. In other words, I am permitted to deny the request for specific reasons. For instance, I do not have to account for disclosures made in order to carry out my own treatment, payment or health care operations. I do not have to account for disclosures of protected health information that are made with your written authorization, since you have the right to receive a copy of any such authorization you might sign. If you desire further information related to this Notice or its contents, or if you have any questions about this Notice or its contents, please feel free to contact me. As the contact person for this practice, I will do my best to answer your questions and to provide you with additional information. Please advise me if you want to obtain a copy of this Notice.
Questions and Complaints*
Questions and Complaints: If you have any question about this notice or if you think I may have violated your privacy rights, please contact me. You may also submit a written complaint to the Sate Department of Health and Human services. I will not retaliate in any way if you choose to file a complaint.
I hereby acknowledge that I have received and have been given an opportunity to read a copy of Notice of Privacy Practices for Athena Counselor, LCSW. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Athena Counselor, LCSW at 314 282 7275.*
- I Agree
Client Signature*
Type your full name
Date*
Date Format: MM slash DD slash YYYY

Contact Information*
AUTHORIZATION FOR USE OR DISCLOSURE OF INFORMATION Athena Counselor, LCSW 314 282 7275 your-email-address@insession.io Address: 99 Bank St, Suite 5B NY, NY 10014
Name*
First Last
Phone*
Email
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
I authorize Athena Counselor, LCSW to disclose and/or obtain information from the following, Name or Company:*
I authorize Athena Counselor, LCSW to disclose and/or obtain information from the above at the following address:*
Street Address Address Line 2 City State ZIP Code
I understand that I have the right to revoke this authorization, in writing, at anytime by submitting written notification to Athena Counselor, LCSW at 99 Bank St, Suite 5B, NY, NY 10014. I also understand, per the Notice of Privacy Practices, that the revocation might not be accepted if this protected health information has been relied upon for reimbursement or coordination of treatment.*
- I Agree
Client Signature*
Type your full name
Date*
Date Format: MM slash DD slash YYYY

Client Intake

Informed Consent

Informed Consent For Online Therapy

Notice of Privacy Practices - HIPAA