Sample New Client Information Form - Insurance Page 4
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4NOTICE OF PRIVACY PRACTICE
The notice in our waiting area describes how psychological and health information about you may be used and
disclosed and how you can get access to this information.
I have read and received (if requested) and understand the privacy practices information. I understand that my
signature on this form acknowledges receipt of these documents and acceptance of the conditions of the privacy
policies of Stone Creek Psychotherapy &Wellness Center.
STATEMENT OF UNDERSTANDING:
I have read and understand this information sheet and informed consent.
______________________________
___________________________
Client
Date
______________________________
___________________________
Clinician
Date
______________________________
___________________________
Parent or Guardian if minor
Date
Regarding release of mental health medical records for adults and minors:
Texas Health and Safety Code, Chapter 611, Mental Health records, specifically Sections:
611.0045 (c) If the professional denies access to any portion of a record, the professional shall give the patient a signed and dated written statement
that having access to the records would be harmful to the patient’s physical, mental, or emotional health and shall include a copy of the written
statement in the patient’s records.
INITIAL ________
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