Intake Form

Consent

I authorize HCC to provide psychotherapy services to me and/or the following person(s)

I am aware that I am responsible for full payment of all charges for services rendered. HCC is not a network provider for any insurance company, so any benefits payable by insurance will be out of network and my responsibility to submit for reimbursement.

I grant permission to HCC to inform my primary care physician that I am receiving psychotherapy services, and I authorize the release of clinical information to my physician.

I grant permission to HCC to inform the following person(s) that I am receiving psychotherapy services, and I authorize the release of clinical information to him/her/them

I have read the HCC Office Policies and agree to abide by those policies.

I have received and read a copy of the Health Insurance Portability and Accountability Act (HIPAA).

Signature (Client or Authorized Party)