Consents & Forms

Below are the various consents and forms that are required, or may be needed, while working with a client:

Most of these forms can and should be completed using the Intake Forms Weblink. If electronic forms are not accessible for client or if you prefer using paper forms, these forms can be physically found in folders on the back of clinic doors and at the clinic office. These forms are available in other languages. If needed, ask the Clinic Administrative Assistant.

Using Weblink to complete forms

When using the weblink to complete necessary forms electronically, you will be prompted to first enter the name and date of birth of the client before accessing the form. See screenshot to the right.

Be sure to enter the name and date of birth of the client for whom the form should be filed. For example, an adult signing a provider release to speak with their psychiatrist would enter their name and date of birth at this screen. For a parent signing a two adult release form regarding child, the child's name and date of birth should be entered at this screen.

Therapy Agreement.pdf

Therapy Agreement

This is the document that helps facilitate the therapist's informed consent conversation. It is critical that it is reviewed and signed by each client at the initial session. All the items you may want/need to discuss with clients during an informed consent conversation may not be physically on this document. It's important that any additional expectations discussed (e.g., "no secrets" policy with couples) are documented in the session summary/case note.

Consent for Recording and Supervision.pdf

Consent to Recording & Supervision

Clients must be informed of their rights and give consent to video recording and supervision, or they CANNOT BE SEEN at our Center. If a client refuses to sign, then the student therapist must end the session and provide the client with other referrals. Therapists must also co-sign the document in applicable areas.

Consent to Teletherapy

This is an electronic form that must be completed before any teletherapy sessions can occur. There will not be a paper copy in the file, but it should be in the electronic record.

Minor Consent.pdf

Minor Consent

If working with children under 18, a legal guardian MUST sign the Minor Consent. The consenting guardian must have the legal right to make decisions regarding their child’s medical/mental health care. In instances where two individuals have legal decision making power, make every effort must be made for this be signed by both guardians. Details regarding legal paperwork may be described in case files where this is applicable.

Two Adult Release regarding Child.pdf

Two Adult Release Regarding Child

If parents are no longer together or have never been together, have them sign the Two adult Release regarding Child that allows them to discuss only information regarding the child(ren). When completing via Intake Forms Weblink, you will need to complete this form for each child in the system. If you are completing this form on paper, you may have one signed and copied into each child's chart.

Custody Papers

When there are formal custody arrangements regarding a minor, we are required to retain a copy of the custody order in the client file. We need to ensure that the parent/guardian has the right to make decisions about the child/children's medical/mental health care. We are not allowed to see child with custody agreements in place without a copy on file. Clients may drop off paperwork, mail it to Peck Hall, or fax it to the clinic.

General Release.pdf

General Release

This release is used to obtain written authorization to speak with any third-party, such as another provider.

Student therapists must have a release signed by the client to make contact with another person about the case. You may not acknowledge someone is even a client unless a release is on file. Sharing any information about a case/client without their written permission is a serious breach of confidentiality. Releases are person specific and must be renewed if there is a change in therapists.

RELEASE AUTHORIZATION for two adult clients.pdf

Two Adult Release

The AAMFT Code of Ethics requires therapists to keep confidences of individuals, even when they are part of a family unit. It is considered best practice to get releases from adult family members for the therapist to speak about them to one another. For Couples/Families each adult must sign a release to talk with the other adult in the case about them. If there is a co-therapy team, it is also best practice to have releases signed by all adults for the two therapists to talk to one another (especially in the event that there are individual sessions).

Watson-Coolhart-21-272-Oral Consent Document.pdf

Research Consent

This must be reviewed with every client who is 18 and older. Each client should indicate whether or not they agree to participate in research. Agreeing to participate or not in research does not impact their ability to receive therapy services from the Center.

Permission to Re-Contact.pdf

Permission to
Re-Contact

This must be reviewed with every client who is 18 and older. Each client should indicate consent to be contacted regarding research. Agreeing to be contacted or not does not impact their ability to receive therapy services from the Center.

Self-Report

Each client (18 and over only) will be asked to complete the Self Report. This can be reached via the Intake Forms Weblink.

Therapist allows the client to complete this on their own.

Assessment

The "New Assessment 2018" form on Intake Forms Weblink is to be completed individually, with each client (18 and over only). This is done in a conversation with the client, and answers are entered into the computer by the therapist during the interview. Completing this individually, allows each individual to talk to the therapist about their confidential information and ability to talk freely to you.

If the client indicates they may hurt themselves or others during the assessment, address this before you end the session. You may need to consult with a supervisor and put a safety plan in place.

Interpreter Release.pdf

Interpreter Release

To be completed anytime therapy is facilitated with an interpreter

RELEASE - TRANSPORTATION.pdf

Transportation Release

To be completed when appointments need to be verified with Medicaid, or another transportation service

RELEASE - GENERAL LTR.pdf

General Letter Release

To be completed when a letter of some type has been released to the client

RELEASE - GENERAL LTR regarding child.pdf

General Letter Release regarding Child

To be completed when a letter of some type about a minor client has been released to their legal parent/guardian

RELEASE AUTHORIZATION regarding child.pdf

General Release regarding Child

This release is used to obtain written authorization from a legal guardian to speak with any third-party, such as another provider, about a minor client

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