Consent and Intake Forms Templates Part 2: Complete Collection for Private Practice 2026

Welcome to Part 2 of our comprehensive consent and intake forms guide for private practice. If you haven't read Part 1, start there for the three essential consent forms every practice needs.

In this part, we'll cover additional consent forms and comprehensive intake questionnaires that streamline your practice operations and ensure complete client information gathering.

Additional Consent Forms

4. Credit Card Authorization Form

Purpose: Authorizes charging a client's credit card for services, missed appointments, and outstanding balances.

When to Use: All clients paying by credit card, especially for recurring services

Template:

CREDIT CARD AUTHORIZATION FORM

[PRACTICE NAME]
[ADDRESS]
[PHONE]

Client Name: _________________________________
Date: _________________________________

PAYMENT AUTHORIZATION

I, _________________________________ (Cardholder Name), authorize [PRACTICE NAME] to charge my credit card for services rendered, missed appointments, and any outstanding balances according to the terms outlined below.

CREDIT CARD INFORMATION

Card Type:  ☐ Visa  ☐ Mastercard  ☐ American Express  ☐ Discover

Card Number: _________________________________
Expiration Date: _____ / _____
CVV Code: _______
Billing ZIP Code: _____________

Cardholder Name (as appears on card): _________________________________
Cardholder Signature: _________________________________

BILLING ADDRESS

Street Address: _________________________________
City: _________________ State: _____ ZIP: _____________
Phone: _________________________________
Email: _________________________________

AUTHORIZATION TERMS

I authorize [PRACTICE NAME] to charge my credit card for the following:

1. SESSION FEES: I authorize charges for each therapy/consultation session at the agreed-upon rate of $______ per session. Charges will be processed on the date of service or within 48 hours.

2. MISSED APPOINTMENTS: I understand that I must provide at least 24 hours notice to cancel or reschedule an appointment. I authorize a charge of $______ (or the full session fee) for appointments missed without proper notice.

3. OUTSTANDING BALANCES: I authorize charges for any outstanding balances on my account. I will be notified before processing charges over $______.

4. INSURANCE CO-PAYS: If applicable, I authorize charges for insurance co-payments, deductibles, and any amounts not covered by my insurance.

PAYMENT PROCESSING

• Charges will be processed within 48 hours of service
• A receipt will be provided via email for each transaction
• I will notify [PRACTICE NAME] immediately of any changes to my credit card information
• This authorization remains in effect until I revoke it in writing
• I understand that I may revoke this authorization at any time by providing written notice

DECLINED TRANSACTIONS

If a charge is declined, I understand that:
• I will be notified immediately
• A $25 processing fee may be applied for declined transactions
• I am responsible for providing updated payment information
• Services may be suspended until payment is received

REFUND POLICY

Refunds, if applicable, will be credited to the same credit card within 7-10 business days.

SECURITY

I understand that my credit card information will be stored securely in compliance with PCI-DSS standards and HIPAA regulations. My information will not be shared with third parties except as necessary to process payments.

ACKNOWLEDGMENT

I have read and understand the terms of this Credit Card Authorization Form. I authorize [PRACTICE NAME] to charge my credit card according to the terms outlined above.

_________________________________    _________________________________
Cardholder Signature                  Date

_________________________________    _________________________________
Provider Signature                    Date

ClinikEHR Implementation:

• Secure, PCI-compliant card storage
• Automatic charging for sessions
• Missed appointment fee automation
• Email receipts
• Declined card notifications
• Easy card updates via client portal

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5. Consent to Record Audio/Video

Purpose: Obtains permission to record sessions for supervision, training, or documentation purposes.

When to Use: When recording sessions for any reason

Template:

CONSENT TO RECORD AUDIO/VIDEO

Client Name: _________________________________
Date of Birth: _________________________________
Date: _________________________________

PURPOSE OF RECORDING

[PRACTICE NAME] requests permission to make audio and/or video recordings of our therapy/consultation sessions for the following purposes:

☐ Clinical supervision and consultation
☐ Training and education
☐ Quality assurance and improvement
☐ Documentation and record-keeping
☐ Research (de-identified)
☐ Other: _________________________________

RECORDING DETAILS

Type of Recording:  ☐ Audio Only  ☐ Video  ☐ Both

Frequency:  ☐ All sessions  ☐ Selected sessions  ☐ As needed

Storage Location:  ☐ Secure encrypted server  ☐ Encrypted local storage

Retention Period: Recordings will be kept for _____ years and then securely destroyed.

WHO WILL HAVE ACCESS

Recordings may be reviewed by:
☐ Treating clinician only
☐ Clinical supervisor
☐ Consultation group members (all bound by confidentiality)
☐ Training purposes (with identifying information removed)
☐ Other: _________________________________

All individuals with access to recordings are bound by professional confidentiality standards and HIPAA regulations.

YOUR RIGHTS

1. VOLUNTARY PARTICIPATION: Participation in recording is completely voluntary. You may decline to be recorded without any effect on the quality of services you receive.

2. SELECTIVE CONSENT: You may consent to recording some sessions but not others. You may request that recording be stopped at any time during a session.

3. REVIEW ACCESS: You have the right to review any recordings made of your sessions upon request.

4. REVOCATION: You may revoke this consent at any time by providing written notice. Revocation will not affect recordings made prior to revocation.

5. CONFIDENTIALITY: All recordings are subject to the same confidentiality protections as your other health information under HIPAA.

SECURITY MEASURES

Recordings will be protected by:
• Encryption during storage and transmission
• Password-protected access
• Secure, HIPAA-compliant servers
• Regular security audits
• Automatic deletion after retention period

EXCEPTIONS TO CONFIDENTIALITY

Recordings are subject to the same exceptions to confidentiality as outlined in your Informed Consent and HIPAA Notice of Privacy Practices, including:
• Imminent danger to self or others
• Suspected child or elder abuse
• Court orders or subpoenas

CONSENT

☐ I CONSENT to audio and/or video recording of my therapy/consultation sessions as described above.

☐ I DO NOT CONSENT to recording of my sessions.

I understand that:
• Recording is voluntary and I may decline without affecting my care
• I may revoke this consent at any time in writing
• I may request that recording be stopped during any session
• Recordings will be stored securely and kept confidential
• I have received a copy of this consent form

_________________________________    _________________________________
Client Signature                      Date

_________________________________    _________________________________
Therapist/Provider Signature          Date

_________________________________    _________________________________
Parent/Guardian Signature (if minor)  Date

REVOCATION OF CONSENT

I hereby revoke my consent to record sessions, effective immediately.

_________________________________    _________________________________
Client Signature                      Date

ClinikEHR Implementation:

• Session-by-session recording consent tracking
• Automatic consent verification before recording
• Secure encrypted storage
• Access logs and audit trails
• Automatic deletion after retention period
• Easy revocation process

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6. Consent for Use of Artificial Intelligence (AI) Tools in Therapy Services

Purpose: Informs clients about AI tool usage and obtains consent for AI-assisted services.

When to Use: When using AI for clinical notes, treatment planning, or other clinical purposes

Template:

CONSENT FOR USE OF ARTIFICIAL INTELLIGENCE (AI) TOOLS IN THERAPY SERVICES

Client Name: _________________________________
Date of Birth: _________________________________
Date: _________________________________

INTRODUCTION

[PRACTICE NAME] uses artificial intelligence (AI) tools to enhance the quality and efficiency of services provided to you. This form explains how AI is used in your care and requests your consent for this use.

WHAT IS AI IN HEALTHCARE?

Artificial Intelligence refers to computer systems that can perform tasks that typically require human intelligence, such as analyzing information, recognizing patterns, and making recommendations. In healthcare, AI tools can assist with documentation, treatment planning, and clinical decision support.

HOW WE USE AI

[PRACTICE NAME] may use AI tools for the following purposes:

☐ CLINICAL DOCUMENTATION: AI assists in generating session notes and treatment summaries based on session content. All AI-generated notes are reviewed and edited by your clinician before being finalized.

☐ TREATMENT PLANNING: AI may suggest evidence-based treatment approaches and interventions based on your presenting concerns and treatment goals. Your clinician makes all final treatment decisions.

☐ SYMPTOM TRACKING: AI may analyze patterns in your symptoms and progress over time to inform treatment adjustments.

☐ ADMINISTRATIVE TASKS: AI assists with scheduling, appointment reminders, and billing processes.

☐ RESEARCH AND QUALITY IMPROVEMENT: De-identified data may be used to improve AI tools and clinical services.

WHAT INFORMATION IS SHARED WITH AI

AI tools may process the following information:
• Session content and clinical observations
• Symptoms and diagnoses
• Treatment goals and progress
• Demographic information (age, gender, etc.)
• Previous treatment history

Your name and other directly identifying information are removed or encrypted before processing by AI tools whenever possible.

AI PROVIDERS WE USE

We use the following AI services:
• [AI SERVICE NAME] for clinical documentation
• [AI SERVICE NAME] for treatment planning
• All providers are HIPAA-compliant Business Associates

PRIVACY AND SECURITY

Your privacy is our top priority. We ensure that:

1. HIPAA COMPLIANCE: All AI tools used are HIPAA-compliant and covered by Business Associate Agreements.

2. DATA ENCRYPTION: Your information is encrypted during transmission and storage.

3. LIMITED ACCESS: Only authorized personnel and approved AI systems have access to your information.

4. NO TRAINING USE: Your data will NOT be used to train AI models unless you provide separate explicit consent for de-identified research use.

5. SECURE STORAGE: All data is stored on secure, HIPAA-compliant servers.

6. AUDIT TRAILS: All AI access to your information is logged and monitored.

LIMITATIONS OF AI

It is important to understand that:

• AI is a TOOL that assists your clinician; it does not replace human clinical judgment
• Your clinician reviews and approves all AI-generated content before it becomes part of your record
• AI recommendations are based on patterns and may not capture your unique circumstances
• Your clinician makes all final decisions about your diagnosis and treatment
• AI tools may occasionally make errors or provide incomplete information

BENEFITS OF AI USE

Potential benefits include:
• More comprehensive and accurate clinical documentation
• Evidence-based treatment recommendations
• Improved efficiency, allowing more time for direct clinical care
• Better tracking of symptoms and progress over time
• Enhanced quality of care through data-driven insights

RISKS OF AI USE

Potential risks include:
• Technical errors or system failures
• Privacy breaches (though we use extensive safeguards)
• Over-reliance on AI recommendations
• Misinterpretation of AI-generated information

YOUR RIGHTS

You have the right to:

1. DECLINE AI USE: You may decline the use of AI tools in your care without affecting the quality of services you receive. Alternative documentation and treatment planning methods will be used.

2. ASK QUESTIONS: You may ask questions about how AI is used in your care at any time.

3. REVIEW AI-GENERATED CONTENT: You may request to see AI-generated notes or recommendations.

4. REVOKE CONSENT: You may revoke this consent at any time by providing written notice.

5. FILE COMPLAINTS: You may file a complaint if you believe AI has been used inappropriately.

HUMAN OVERSIGHT

All AI-generated content is reviewed, edited, and approved by your licensed clinician before being finalized. Your clinician maintains full responsibility for your care and all clinical decisions.

CONSENT

☐ I CONSENT to the use of AI tools in my therapy/healthcare services as described above.

☐ I DO NOT CONSENT to the use of AI tools. I understand that alternative methods will be used.

I acknowledge that:
• I have read and understand this consent form
• I have had the opportunity to ask questions
• I understand how AI will be used in my care
• I understand the benefits and risks
• I understand that AI assists but does not replace my clinician
• I may revoke this consent at any time
• I have received a copy of this form

_________________________________    _________________________________
Client Signature                      Date

_________________________________    _________________________________
Clinician Signature                   Date

_________________________________    _________________________________
Parent/Guardian Signature (if minor)  Date

ClinikEHR Implementation:

• AI consent tracking per client
• Automatic consent verification before AI use
• Transparent AI usage logs
• Human review workflow for AI-generated content
• Easy opt-out process
• Compliance with emerging AI regulations

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Intake Forms and Questionnaires

7. COVID-19 Pre-Appointment Screening Questionnaire

Purpose: Screens clients for COVID-19 symptoms and exposure before in-person appointments.

When to Use: All in-person appointments (can be completed day of appointment)

Template:

COVID-19 PRE-APPOINTMENT SCREENING QUESTIONNAIRE

Client Name: _________________________________
Appointment Date: _________________________________
Appointment Time: _________________________________

Please complete this screening questionnaire before your appointment. Your honest responses help us maintain a safe environment for all clients and staff.

CURRENT SYMPTOMS

In the past 48 hours, have you experienced any of the following symptoms?

☐ Fever (100.4°F/38°C or higher) or chills
☐ Cough (new or worsening)
☐ Shortness of breath or difficulty breathing
☐ Fatigue or unusual tiredness
☐ Muscle or body aches
☐ Headache
☐ New loss of taste or smell
☐ Sore throat
☐ Congestion or runny nose
☐ Nausea, vomiting, or diarrhea
☐ None of the above

EXPOSURE AND TESTING

1. In the past 10 days, have you tested positive for COVID-19?
   ☐ Yes  ☐ No

2. In the past 10 days, have you been in close contact (within 6 feet for 15 minutes or more) with someone who tested positive for COVID-19?
   ☐ Yes  ☐ No

3. Are you currently in quarantine or isolation for COVID-19?
   ☐ Yes  ☐ No

4. Are you currently waiting for COVID-19 test results?
   ☐ Yes  ☐ No

VACCINATION STATUS (Optional)

Are you fully vaccinated against COVID-19?
☐ Yes  ☐ No  ☐ Prefer not to answer

SAFETY PROTOCOLS

To maintain a safe environment, we require all clients to:
• Wear a mask if experiencing any symptoms
• Sanitize hands upon arrival
• Maintain social distancing when possible
• Notify us immediately if you develop symptoms within 48 hours after your appointment

ATTESTATION

I attest that the information provided above is true and accurate to the best of my knowledge. I understand that if I answered "Yes" to any of the symptom or exposure questions, I may be asked to reschedule my appointment or participate via telehealth.

I understand that [PRACTICE NAME] is taking precautions to reduce COVID-19 transmission, but cannot guarantee a completely risk-free environment.

_________________________________    _________________________________
Client Signature                      Date

_________________________________    _________________________________
Staff Signature                       Date

SCREENING RESULT

☐ CLEARED for in-person appointment
☐ TELEHEALTH RECOMMENDED
☐ RESCHEDULE RECOMMENDED

Notes: _________________________________

ClinikEHR Implementation:

• Sent automatically 24 hours before appointment
• Mobile-friendly completion
• Automatic flagging of concerning responses
• Staff notification of screening results
• Telehealth conversion option
• Easy rescheduling if needed

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8. Standard Intake Questionnaire Template

Purpose: Gathers comprehensive client information for initial assessment and treatment planning.

When to Use: All new clients before or during first session

Template:

CONFIDENTIAL INTAKE QUESTIONNAIRE

[PRACTICE NAME]
[ADDRESS] | [PHONE] | [EMAIL]

Date: _________________________________

PERSONAL INFORMATION

Full Name: _________________________________
Preferred Name: _________________________________
Date of Birth: _____ / _____ / _____     Age: _____
Gender:  ☐ Male  ☐ Female  ☐ Non-binary  ☐ Prefer to self-describe: _____________

Address: _________________________________
City: _________________ State: _____ ZIP: _____________
Phone (Primary): _________________________________
Phone (Secondary): _________________________________
Email: _________________________________
Preferred Contact Method:  ☐ Phone  ☐ Email  ☐ Text

Marital Status:  ☐ Single  ☐ Married  ☐ Partnered  ☐ Divorced  ☐ Widowed

Emergency Contact Name: _________________________________
Relationship: _________________________________
Phone: _________________________________

EMPLOYMENT & INSURANCE

Occupation: _________________________________
Employer: _________________________________
Work Phone: _________________________________

Insurance Company: _________________________________
Policy Holder Name: _________________________________
Policy Number: _________________________________
Group Number: _________________________________

REFERRAL INFORMATION

How did you hear about our practice?
☐ Insurance provider directory
☐ Online search (Google, etc.)
☐ Psychology Today or other directory
☐ Friend or family referral
☐ Physician referral: _________________________________
☐ Other: _________________________________

PRESENTING CONCERNS

What brings you to therapy/consultation at this time?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

How long have you been experiencing these concerns?
_________________________________________________________________

What would you like to accomplish in therapy?
_________________________________________________________________
_________________________________________________________________

CURRENT SYMPTOMS

Please check any symptoms you are currently experiencing:

MOOD:
☐ Depressed mood
☐ Irritability
☐ Mood swings
☐ Loss of interest in activities
☐ Feelings of hopelessness

ANXIETY:
☐ Excessive worry
☐ Panic attacks
☐ Social anxiety
☐ Specific phobias
☐ Obsessive thoughts
☐ Compulsive behaviors

SLEEP:
☐ Difficulty falling asleep
☐ Difficulty staying asleep
☐ Sleeping too much
☐ Nightmares

EATING:
☐ Changes in appetite
☐ Overeating
☐ Restricting food
☐ Binge eating
☐ Purging behaviors

COGNITIVE:
☐ Difficulty concentrating
☐ Memory problems
☐ Racing thoughts
☐ Intrusive thoughts

BEHAVIORAL:
☐ Withdrawal from others
☐ Increased substance use
☐ Self-harm behaviors
☐ Suicidal thoughts

OTHER:
☐ Relationship problems
☐ Work/school difficulties
☐ Trauma symptoms
☐ Grief/loss
☐ Other: _________________________________

MENTAL HEALTH HISTORY

Have you received mental health treatment before?  ☐ Yes  ☐ No

If yes, please provide details:

Previous Therapist/Provider: _________________________________
Dates of Treatment: _________________________________
Type of Treatment: _________________________________
Was it helpful?  ☐ Yes  ☐ Somewhat  ☐ No

Have you ever been hospitalized for mental health reasons?  ☐ Yes  ☐ No
If yes, when and where? _________________________________

Have you ever been prescribed psychiatric medication?  ☐ Yes  ☐ No
If yes, please list medications and dates: _________________________________

CURRENT MEDICATIONS

Please list all medications you are currently taking (including over-the-counter):

Medication Name          Dosage          Prescribing Doctor
_________________       _______         _________________
_________________       _______         _________________
_________________       _______         _________________

MEDICAL HISTORY

Current Medical Conditions: _________________________________
_________________________________________________________________

Recent Surgeries or Hospitalizations: _________________________________
_________________________________________________________________

Allergies (medications, foods, etc.): _________________________________

Primary Care Physician: _________________________________
Phone: _________________________________

Date of Last Physical Exam: _________________________________

SUBSTANCE USE

Do you currently use:

Alcohol:  ☐ Never  ☐ Occasionally  ☐ Weekly  ☐ Daily
         Amount per occasion: _________________________________

Tobacco:  ☐ Never  ☐ Former user  ☐ Current user
         Amount per day: _________________________________

Cannabis:  ☐ Never  ☐ Occasionally  ☐ Weekly  ☐ Daily

Other substances:  ☐ No  ☐ Yes (please specify): _________________________________

Have you ever been concerned about your substance use?  ☐ Yes  ☐ No

FAMILY HISTORY

Please indicate if any blood relatives have experienced:

☐ Depression
☐ Anxiety disorders
☐ Bipolar disorder
☐ Schizophrenia
☐ Substance abuse
☐ Suicide attempts or completion
☐ Other mental health conditions: _________________________________

TRAUMA HISTORY

Have you experienced any of the following? (Check all that apply)

☐ Physical abuse
☐ Sexual abuse
☐ Emotional abuse
☐ Neglect
☐ Domestic violence
☐ Combat exposure
☐ Serious accident or injury
☐ Natural disaster
☐ Sudden loss of loved one
☐ Other traumatic event: _________________________________

SOCIAL HISTORY

Relationship Status: _________________________________
Children:  ☐ Yes  ☐ No     If yes, ages: _________________________________

Living Situation:
☐ Alone
☐ With partner/spouse
☐ With family
☐ With roommates
☐ Other: _________________________________

Support System: Who do you turn to for support?
_________________________________________________________________

Religious/Spiritual Affiliation (if relevant to treatment): _________________________________

SAFETY ASSESSMENT

In the past month, have you had thoughts of harming yourself?  ☐ Yes  ☐ No

In the past month, have you had thoughts of harming others?  ☐ Yes  ☐ No

If you answered yes to either question above, please provide details:
_________________________________________________________________

Do you have access to firearms?  ☐ Yes  ☐ No

ADDITIONAL INFORMATION

Is there anything else you would like your therapist/provider to know?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

ACKNOWLEDGMENT

I certify that the information provided above is accurate and complete to the best of my knowledge. I understand that this information will be kept confidential and used to provide appropriate care.

_________________________________    _________________________________
Client Signature                      Date

_________________________________    _________________________________
Clinician Signature                   Date

ClinikEHR Implementation:

• Digital intake forms sent before first appointment
• Mobile-friendly completion
• Automatic flagging of safety concerns
• Integration with clinical notes
• Progress tracking over time
• Customizable for different specialties

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9. Authorization for Release of Information

Purpose: Authorizes sharing of protected health information with specified individuals or organizations.

When to Use: When coordinating care with other providers, sharing records with insurance, or at client request

Template:

AUTHORIZATION FOR RELEASE OF INFORMATION

Client Name: _________________________________
Date of Birth: _________________________________
Client ID/Medical Record #: _________________________________

I hereby authorize [PRACTICE NAME] to release protected health information as specified below.

INFORMATION TO BE RELEASED FROM:

Provider/Organization Name: _________________________________
Address: _________________________________
City: _________________ State: _____ ZIP: _____________
Phone: _________________________________
Fax: _________________________________

INFORMATION TO BE RELEASED TO:

Provider/Organization Name: _________________________________
Address: _________________________________
City: _________________ State: _____ ZIP: _____________
Phone: _________________________________
Fax: _________________________________
Email: _________________________________

PURPOSE OF DISCLOSURE

☐ Continuity of care/coordination of treatment
☐ Insurance/benefits determination
☐ Legal proceedings
☐ Personal use
☐ School/educational purposes
☐ Disability determination
☐ Other: _________________________________

TYPE OF INFORMATION TO BE RELEASED

☐ Complete medical/clinical record
☐ Specific date range: From _____ / _____ / _____ To _____ / _____ / _____
☐ Specific information only (check all that apply):
   ☐ Intake assessment
   ☐ Treatment plan
   ☐ Progress notes
   ☐ Discharge summary
   ☐ Psychological testing results
   ☐ Medication records
   ☐ Diagnosis
   ☐ Treatment dates and attendance
   ☐ Other: _________________________________

SENSITIVE INFORMATION

I understand that my health information may include sensitive information. I specifically authorize (or do not authorize) release of the following:

☐ AUTHORIZE    ☐ DO NOT AUTHORIZE
Mental health information

☐ AUTHORIZE    ☐ DO NOT AUTHORIZE
Substance abuse treatment information (42 CFR Part 2 protected)

☐ AUTHORIZE    ☐ DO NOT AUTHORIZE
HIV/AIDS testing or treatment information

☐ AUTHORIZE    ☐ DO NOT AUTHORIZE
Genetic testing information

☐ AUTHORIZE    ☐ DO NOT AUTHORIZE
Sexual assault or domestic violence information

METHOD OF RELEASE

☐ Mail (regular)
☐ Mail (certified)
☐ Fax
☐ Secure email
☐ Electronic health record system
☐ Pick up in person (photo ID required)
☐ Other: _________________________________

EXPIRATION

This authorization will expire:

☐ One year from the date signed
☐ Upon completion of treatment
☐ On this specific date: _____ / _____ / _____
☐ Upon occurrence of this event: _________________________________

If no expiration is specified, this authorization will expire one year from the date signed.

YOUR RIGHTS

I understand that:

1. I have the right to revoke this authorization at any time by submitting a written request to [PRACTICE NAME]. The revocation will not apply to information already released.

2. I may refuse to sign this authorization. My refusal to sign will not affect my ability to receive treatment, payment, enrollment, or eligibility for benefits unless the information is necessary for such purposes.

3. Information released pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations (HIPAA).

4. I have the right to receive a copy of this authorization.

5. I will not be charged a fee for copying and mailing records if the release is for my own use or for determining eligibility for benefits. Fees may apply for other purposes.

6. I may inspect or receive a copy of the information to be disclosed.

ACKNOWLEDGMENT

I have read and understand this authorization. I have had the opportunity to ask questions and all my questions have been answered. I voluntarily authorize the release of my health information as described above.

_________________________________    _________________________________
Client Signature                      Date

_________________________________    _________________________________
Parent/Guardian Signature (if minor)  Date

_________________________________    _________________________________
Witness Signature                     Date

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FOR OFFICE USE ONLY

Date Information Released: _________________________________
Method of Release: _________________________________
Released By: _________________________________
Pages Released: _________________________________

REVOCATION OF AUTHORIZATION

I hereby revoke the authorization signed on _____ / _____ / _____ for release of information to _________________________________.

_________________________________    _________________________________
Client Signature                      Date

Date Revocation Received: _________________________________

ClinikEHR Implementation:

• Digital authorization with e-signature
• Automatic expiration tracking
• Secure transmission to recipients
• Audit log of all releases
• Easy revocation process
• HIPAA-compliant documentation

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10. Consent for Treatment of a Minor

Purpose: Obtains parental/guardian consent for treatment of minors and clarifies confidentiality boundaries.

When to Use: All clients under 18 years old (or state-specific age of majority)

Template:

CONSENT FOR TREATMENT OF A MINOR

Minor Client Name: _________________________________
Date of Birth: _________________________________
Age: _____

Parent/Guardian Information:

Parent/Guardian 1:
Name: _________________________________
Relationship to Minor: _________________________________
Address: _________________________________
Phone: _________________________________
Email: _________________________________

Parent/Guardian 2:
Name: _________________________________
Relationship to Minor: _________________________________
Address: _________________________________
Phone: _________________________________
Email: _________________________________

CUSTODY AND CONSENT

Legal custody status:
☐ Both parents have joint legal custody
☐ Sole custody (specify parent): _________________________________
☐ Legal guardian
☐ Other arrangement: _________________________________

I/We certify that I/we have the legal authority to consent to mental health treatment for the above-named minor.

Court orders or custody agreements affecting treatment decisions:
☐ None
☐ Yes (please attach copy or provide details): _________________________________

CONSENT FOR TREATMENT

I/We hereby request and consent to mental health services for the above-named minor from [PRACTICE NAME] and [THERAPIST NAME].

I/We understand that:

1. TREATMENT APPROACH: The therapist will use evidence-based approaches appropriate for the minor's age and presenting concerns.

2. PARENT INVOLVEMENT: Parent/guardian involvement is an important part of treatment. The therapist will determine the appropriate level of parent involvement based on the minor's age, presenting concerns, and clinical judgment.

3. CONFIDENTIALITY WITH MINORS: Therapy is most effective when there is trust between the therapist and client. The therapist will maintain confidentiality with the minor to build this trust, with the following exceptions:

INFORMATION SHARED WITH PARENTS:
• General progress updates
• Treatment goals and approaches
• Attendance and participation
• Recommendations for additional services

INFORMATION THAT MAY BE KEPT CONFIDENTIAL:
• Specific content of therapy sessions
• Personal thoughts and feelings shared in session
• Age-appropriate private matters

EXCEPTIONS - INFORMATION THAT MUST BE DISCLOSED:
• Risk of harm to self (suicidal thoughts or behaviors)
• Risk of harm to others
• Suspected abuse or neglect
• Court order or legal requirement
• Medical emergency

4. THERAPIST DISCRETION: The therapist will use professional judgment to determine what information to share with parents, balancing the minor's privacy rights with parents' need to know and legal rights.

5. FAMILY SESSIONS: The therapist may recommend family or parent sessions as part of treatment.

PARENT/GUARDIAN RESPONSIBILITIES

I/We agree to:

• Ensure the minor attends scheduled appointments
• Provide accurate information about the minor's history and current functioning
• Inform the therapist of any significant changes in the minor's life
• Follow through with recommendations made by the therapist
• Pay for services as agreed
• Provide 24 hours notice for cancellations
• Communicate concerns about treatment to the therapist

COMMUNICATION PREFERENCES

The therapist may contact me/us regarding:

Parent/Guardian 1:
☐ Appointment reminders
☐ Billing matters
☐ Progress updates
☐ Clinical concerns
Preferred contact method:  ☐ Phone  ☐ Email  ☐ Text

Parent/Guardian 2:
☐ Appointment reminders
☐ Billing matters
☐ Progress updates
☐ Clinical concerns
Preferred contact method:  ☐ Phone  ☐ Email  ☐ Text

MINOR'S ASSENT

For minors age 12 and older, we request the minor's assent (agreement) to participate in treatment.

Minor's Statement:
I understand that I will be meeting with a therapist to talk about things that are bothering me or that I want to work on. I understand that what I talk about is private, but the therapist may need to tell my parents about some things to keep me safe. I agree to participate in therapy.

_________________________________    _________________________________
Minor's Signature (if age 12+)        Date

PARENT/GUARDIAN CONSENT

I/We have read and understand this consent form. I/We have had the opportunity to ask questions and all questions have been answered. I/We voluntarily consent to mental health treatment for the above-named minor.

_________________________________    _________________________________
Parent/Guardian 1 Signature           Date

_________________________________    _________________________________
Parent/Guardian 2 Signature           Date

_________________________________    _________________________________
Therapist Signature                   Date

SPECIAL CIRCUMSTANCES

☐ Divorced/separated parents: Both parents will receive updates unless court order specifies otherwise
☐ Non-custodial parent restrictions: _________________________________
☐ Other special circumstances: _________________________________

ClinikEHR Implementation:

• Separate parent and minor portals
• Age-appropriate confidentiality settings
• Automatic parent notification for safety concerns
• Custody arrangement documentation
• Flexible communication preferences
• Minor assent tracking

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11. Third Party Financial Responsibility Agreement

Purpose: Establishes financial responsibility when someone other than the client is paying for services.

When to Use: When parents pay for adult children, employers pay for employees, or any third-party payment arrangement

Template:

THIRD PARTY FINANCIAL RESPONSIBILITY AGREEMENT

Client Receiving Services:
Name: _________________________________
Date of Birth: _________________________________
Address: _________________________________
Phone: _________________________________
Email: _________________________________

Financially Responsible Party:
Name: _________________________________
Relationship to Client: _________________________________
Address: _________________________________
Phone: _________________________________
Email: _________________________________

FINANCIAL RESPONSIBILITY

I, _________________________________ (Financially Responsible Party), agree to assume full financial responsibility for services provided by [PRACTICE NAME] to _________________________________ (Client).

SERVICES AND FEES

Service Type: _________________________________
Session Fee: $_______ per session
Frequency: _________________________________
Estimated monthly cost: $_______

Additional fees I am responsible for:
☐ Intake assessment: $_______
☐ Psychological testing: $_______
☐ Report writing: $_______
☐ Missed appointment fees: $_______
☐ Other: _________________________________

PAYMENT TERMS

Payment method:
☐ Credit card on file (charged after each session)
☐ Monthly invoice (due within 15 days)
☐ Other: _________________________________

I understand that:

1. TIMELY PAYMENT: Payment is due at the time of service or as specified above. Late payments may incur a fee of $_______ or _____% per month.

2. MISSED APPOINTMENTS: I am responsible for the full session fee for appointments missed without 24 hours notice.

3. INSURANCE: 
   ☐ Services will be billed to insurance (I am responsible for co-pays, deductibles, and non-covered services)
   ☐ Services will not be billed to insurance (I am responsible for full fee)

4. COLLECTIONS: If my account becomes delinquent, I am responsible for all collection costs, including reasonable attorney fees.

5. PRICE CHANGES: I will be notified 30 days in advance of any fee increases.

CONFIDENTIALITY AND COMMUNICATION

I understand that as the financially responsible party:

☐ I WILL receive billing statements and payment receipts
☐ I WILL receive appointment reminders
☐ I WILL receive general information about attendance

☐ I WILL NOT receive clinical information without client's written authorization
☐ I WILL NOT receive detailed session notes or treatment information
☐ I WILL NOT be informed of session content

The client's confidentiality will be maintained in accordance with HIPAA regulations and professional ethics. Clinical information will only be shared with my written authorization from the client (or parent/guardian if client is a minor).

CLIENT ACKNOWLEDGMENT

I, _________________________________ (Client), acknowledge that _________________________________ (Financially Responsible Party) has agreed to pay for my therapy services.

I understand that:

• I am ultimately responsible for payment if the financially responsible party does not pay
• I may receive collection notices if payment is not made
• Services may be suspended if payment is not received
• My confidentiality will be maintained as described above

☐ I authorize the financially responsible party to receive billing statements and appointment reminders
☐ I authorize the financially responsible party to receive general attendance information
☐ I authorize the financially responsible party to receive clinical updates (requires separate Release of Information form)

TERMINATION OF AGREEMENT

This agreement may be terminated by:

• Either party with 30 days written notice
• Automatic termination when services end
• Mutual agreement

Upon termination, the client becomes financially responsible for all services. Any outstanding balance remains the responsibility of the financially responsible party.

ACKNOWLEDGMENT

I have read and understand this Third Party Financial Responsibility Agreement. I agree to the terms outlined above.

_________________________________    _________________________________
Financially Responsible Party Signature    Date

_________________________________    _________________________________
Client Signature                      Date

_________________________________    _________________________________
Provider Signature                    Date

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FOR OFFICE USE ONLY

Payment method on file: _________________________________
Billing frequency: _________________________________
Special billing instructions: _________________________________

ClinikEHR Implementation:

• Separate billing and clinical portals
• Automatic invoice generation
• Payment tracking and reminders
• Confidentiality-compliant billing statements
• Easy payment method updates
• Outstanding balance alerts

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Best Practices for Managing Intake Forms

Digital vs. Paper Forms

Digital Forms (Recommended):

• Complete before first appointment
• Automatic data entry into EHR
• Reduced errors and illegible handwriting
• Environmentally friendly
• Easier updates and version control
• Better compliance tracking

When to Use Paper:

• Clients without internet access
• Elderly or technology-averse clients
• Backup for system outages
• Legal requirements in some jurisdictions

Timing and Workflow

Before First Appointment:

1. Send intake packet 3-5 days before first session
2. Include: Intake questionnaire, consent forms, financial agreements
3. Send reminder 24 hours before if not completed
4. Allow 30-45 minutes for completion

During First Session:

1. Review completed forms for accuracy
2. Clarify any unclear responses
3. Address questions about consent and confidentiality
4. Obtain signatures on any incomplete forms
5. Provide copies of signed documents

Ongoing Management:

1. Update forms annually or when circumstances change
2. Re-consent when adding new services (e.g., telehealth, AI tools)
3. Keep all versions of forms for legal compliance
4. Regular audits to ensure all required forms are current

Form Customization Tips

Adapt for Your Specialty:

• Mental health: Add detailed symptom checklists
• Medical: Include comprehensive medical history
• Pediatric: Age-appropriate language and parent sections
• Substance abuse: Detailed substance use history
• Couples therapy: Relationship-specific questions

Cultural Considerations:

• Offer forms in multiple languages
• Include diverse gender identity options
• Respect cultural attitudes toward mental health
• Consider literacy levels in your community

Legal Compliance:

• Consult with attorney for state-specific requirements
• Update forms when laws change
• Include all required HIPAA elements
• Maintain proper record retention

Storage and Security

Digital Storage:

• HIPAA-compliant, encrypted servers
• Access controls and audit logs
• Regular backups
• Secure transmission (no regular email)

Paper Storage:

• Locked filing cabinets
• Limited access
• Proper disposal (shredding)
• Conversion to digital when possible

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Frequently Asked Questions

How long should I keep completed intake forms? Keep intake forms for the same retention period as clinical records: typically 7 years after the last date of service for adults, and until age 25 (or 7 years after last service, whichever is longer) for minors. Check your state's specific requirements as they vary.

Can I charge clients for completing intake forms? Generally, no. Intake forms are considered part of the initial assessment, which is billed as part of the first session. However, extensive psychological testing or comprehensive evaluations that require significant time beyond a standard session may be billable separately.

What if a client refuses to sign a consent form? Explore their concerns and provide clarification. If they still refuse to sign essential forms (informed consent, HIPAA notice), you may need to decline to provide services, as these forms protect both you and the client. Document the refusal and your response in the clinical record.

Do I need new consent forms when switching to telehealth? Yes, obtain specific telehealth consent that addresses technology risks, privacy limitations, emergency procedures, and technical requirements. This can be a separate form or an addendum to your existing informed consent. See Part 1 of this series for a complete telehealth consent template.

How do I handle intake forms for clients who don't speak English? Provide forms in the client's primary language whenever possible. Use professional translation services, not family members or online translators. If translated forms aren't available, use a qualified interpreter to explain forms and document that interpretation was provided. ClinikEHR supports multiple languages for intake forms.

Can I use electronic signatures on consent forms? Yes, electronic signatures are legally valid under the ESIGN Act and UETA, provided your system maintains proper authentication, audit trails, and security. Use HIPAA-compliant e-signature platforms, not general services like DocuSign's basic plan. ClinikEHR includes compliant e-signature functionality.

What's the difference between consent and authorization? Consent is agreement to receive treatment and standard uses of health information (treatment, payment, operations). Authorization is specific permission to disclose health information for purposes beyond standard treatment, such as releasing records to a third party or using information for research.

Do I need separate consent for using AI in my practice? Yes, it's best practice to obtain specific consent for AI use, especially for clinical documentation or treatment planning. Clients should understand what AI tools you use, how their data is processed, and that human oversight is maintained. This transparency builds trust and ensures informed consent. See template #6 above for a complete AI consent form.

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Streamline Your Intake Process with ClinikEHR

Managing multiple consent and intake forms can be overwhelming, but it doesn't have to be. ClinikEHR provides:

✅ Complete Form Library - All templates from this guide, customizable for your practice ✅ Digital Intake - Clients complete forms online before their first appointment ✅ Automatic Reminders - No more chasing clients for incomplete paperwork ✅ E-Signatures - HIPAA-compliant electronic signatures with full audit trails ✅ Smart Workflows - Forms automatically route based on client type and services ✅ Compliance Tracking - Never miss an expired consent or required update ✅ Secure Storage - Encrypted, HIPAA-compliant document management ✅ Multi-Language Support - Serve diverse client populations effectively

Ready to modernize your intake process? Start your free trial and see how ClinikEHR can save you hours every week while improving client experience and compliance.

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Complete Your Forms Collection

This is Part 2 of our comprehensive consent and intake forms series:

📋 Part 1: Essential Consent Forms - Informed consent for psychotherapy, telehealth consent, and HIPAA notice of privacy practices

📋 Part 2: Additional Forms (You are here) - Credit card authorization, recording consent, AI consent, COVID screening, intake questionnaire, release of information, minor consent, and third-party financial agreements

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Conclusion

Comprehensive intake and consent forms are the foundation of a well-run private practice. They protect you legally, ensure clients are fully informed, streamline operations, and demonstrate professionalism.

The forms in this guide cover the most common scenarios in private practice, but remember to:

• Customize forms for your specific specialty and state requirements
• Review and update forms annually
• Consult with an attorney for legal compliance
• Use technology to automate and streamline the process
• Focus on client experience while maintaining thoroughness

With proper forms and systems in place, you can spend less time on paperwork and more time providing excellent care to your clients.

Need help implementing these forms in your practice? ClinikEHR makes it easy with ready-to-use templates, digital workflows, and automatic compliance tracking. Get started today with a free trial.

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Disclaimer: This article provides general information and templates for educational purposes. It does not constitute legal advice. Consult with an attorney licensed in your state to ensure your forms comply with applicable laws and regulations.