Patient Registration

Items with a * are required.

Step 1 of 3

Patient Registration
Today's Date
MM slash DD slash YYYY
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Mobile Phone
Email
How do you prefer to be contacted?
Insurance Name
Insurance Type (PPO, MCO, etc)
Insurance Policy Number
Insurance Group Number
Referred by
Emergency Contact*
Emergency Contact Phone*
Relationship
Consent*
I attest the information above is correct to the best of my knowledge.

Confidentiality Statement
Confidentiality Consent*
Some important issues regarding confidentiality need to be understood as we begin our work together. Please review this material carefully so that we may discuss any questions or concerns.

In general, law protects the confidentiality of all communications between a patient and treatment provider. I can only release information about our work to others with your written permission. There are a few exceptions, however.

In most judicial proceedings you have the right to prevent me from testifying. However, in child custody proceedings, adoption proceedings, and proceedings in which your emotional condition is an important element, a judge may require my testimony if it is determined that resolution of the issues before the court requires it. If you are involved in litigation, or are anticipating litigation, and you choose to include your mental or emotional state as part of the litigation, I may have to reveal part or all of your treatment or evaluation records.

If you are called as a witness in criminal proceedings, opposing counsel may have some limited access to your treatment records. My testimony may also be ordered in other cases including legal proceedings relating to psychiatric hospitalization, malpractice and disciplinary proceedings, court ordered psychological evaluations, and certain legal cases following the death of a client.

In addition, there are some circumstances when I am required to breach confidentiality without a patient's permission. This occurs if I suspect the neglect or abuse of a minor, in which case I must file a report with the appropriate State agency. If, in my professional judgment, I believe that a patient is threatening serious harm to another, I am required to take protective action, which may include notifying the police, warning the intended victim, or seeking the client's hospitalization. If a client threatens to harm himself or herself, I may be required to seek hospitalization.

The clear intent of these requirements is that a treatment provider has both a legal and ethical responsibility to take action to protect endangered individuals from harm when his or her professional judgment indicates that such danger exists. Fortunately, these situations rarely arise in my practice.

There are several other matters concerning confidentiality:

1. I may occasionally find it helpful or necessary to consult about a case with another professional. In these consultations I make every effort to avoid revealing the identity of the client. The consultant is, of course, also legally bound to maintain confidentiality. If I feel that it would be helpful to refer you to another professional for consultation then, of course, with your authorization, I will discuss your case with her or him.

2. I am required to maintain complete treatment records. Patients are entitled to receive a copy of these records, unless I believe the information would be emotionally damaging and, in such cases, the records must be made available to the patient's appropriate designee.

3. If you use third party reimbursement, I am required to provide the insurer with a clinical diagnosis and sometimes a treatment plan or summary. If you request it, I will provide you with a copy of any report to submit.

4. If you are under eighteen years of age, please be aware that while the specific content of our communications is confidential, your parents have a right to receive general information on the progress of the treatment. Your parents may also request a copy of your record from me.

5. Under current South Carolina law, in group and family therapy and in marital therapy all participants are required to consent to the release of information. One marital partner may not waive privilege for another. In cases of marital therapy, therefore, the record may be released only if both parties waive privilege or release of the record is court ordered.

6. At times, I will be using a cellular phone to contact you or return your calls. Please be aware that I will not notify you when I am using such a device so if the information you are discussing requires a more secure level of confidentiality, please let me know so I can arrange to contact you in another way.

7. I routinely use a fax machine in communication with other agencies. I will only release information that you have authorized me to release and do send these with a cover sheet that includes a confidentiality statement but this does not insure that the fax is received in the proper place or handled in a confidential matter once it is received. You may pick up and hand carry documents to agencies if you wish. I will also mail documents on special request.

8. I will reply to email messages sent to me and I will make effort to limit the type of information discussed in these messages but again it is important to stress that email is not a confidential mode of communication and should not be utilized if you require a higher degree of security.

While this summary of exceptions to confidentiality should prove helpful in informing you about potential problems, you should be aware that the laws governing these issues are often complex. I encourage our active discussion of these issues. However, if you need more specific advice, formal legal consultation may be desirable.
I agree to the privacy policy.

Forms and Fees

Step 1 of 3

Patient Registration

Consent for Treatment Form

Confidentiality Statement