Special Instructions for completing the authorization for the use and disclosure of Psychotherapy Notes. HIPAA provides special protections to certain medical records known as “Psychotherapy Notes”. All Psychotherapy Notes recorded on any medium (i.e., paper, electronic) by a mental health professional (such as a psychologist or a psychiatrist) must be kept by the author and filed separate from the rest of the client’s medical records to maintain a higher standard of protection. “Psychotherapy Notes” are defined under HIPAA as notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and are separate the rest of the individual’s medical records. Excluded from “Psychotherapy Notes” definition are the following: (a) medication prescription and monitoring, (b) counseling session start and stop times, (c) the modalities and frequencies of treatment furnished, (d) the results of clinical tests, and (e) any summary of: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. My signature indicates I understand HIPAA Authorizations and a separate mental health information disclosure form must be signed to grant permission to discuss protected client information. Client Name: Signature: Date: Debit/Credit Card Authorization Form Forever Hope Counseling requires a credit card on file to secure services with our therapists. Please inform the front desk before your sessions begin if you have a preference to pay with cash or check; however, you must still provide a credit card for your file. Name on the Card: Type of Card: Visa MC Discover *American Express is not accepted Card Number Expiration Date Security Code Billing Address City, State, Zip Phone Number E-mail Address By signing this form, you authorize Forever Hope Counseling & Educational Services, LLC to charge this card for clinical, academic, or behavioral services provided for . This card will be charged for any fees related to these services, such as: missed appointments or same day cancellations. If in the event your credit card is declined, or is not accepted by our credit card system, you agree to offer alternative credit card or to pay by cash or check until we have found a solution to your original preferred bank card. We are unable to schedule appointments with your therapist if there is a balance on your account. Cardholder Signature: Date:
