Helping You Make It Happen
Helping You Make It Happen
Child Registration Packet (15 years old and under)This packet is required for children ages 15 and under. It includes parent/guardian information, child history, and consent forms to begin services. Child Assessment Packet(To be completed in addition to the Child Registration Form if your child is 15 years or younger.)This form provides additional details about your …
HIPAA NOTICE OF PRIVACY PRACTICES As required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice of Privacy Practices …
Consent and Agreement for ServicesThis form explains our policies, your rights as a client, and what you can expect from therapy. By signing, you acknowledge that you understand the services we provide and agree to participate in treatment under these guidelines.
Annual Update FormEach year, we ask our clients to complete an Annual Update Form to ensure we have the most accurate and up-to-date information on file. This helps us: Completing the form takes just a few minutes and allows us to serve you more smoothly throughout the year. Q: When do I need to complete …
Understanding Your Rights to Mental Health Care ConfidentialityYour privacy is a priority. Pellicer Counseling LLC follows HIPAA privacy rules. Our full privacy notice is available in your introductory packet and on our website at PellicerCounseling.com. Your therapist will not share your information without your written consent, except for billing purposes. Confidentiality may be broken in …
Agreement for Parents of Minor ChildrenWhen a child participates in therapy, it is important that parents or guardians understand and agree to the responsibilities involved. Our Agreement for Parents of Minor Children outlines expectations around communication, attendance, confidentiality, and the ways parents can best support the therapeutic process. This form ensures that everyone is on …
Divorced Parents Policy AgreementWhen parents are divorced or separated, clear boundaries and agreements are essential to ensure that therapy remains a safe and supportive space for the child. Our Divorced Parents Policy Agreement explains how information will be shared, what is required for consent, and the expectations for communication with both parents. This helps prevent …