Consent Form

New Client Registration

Please fill in the form below
COVID-19 Support Services: Are you a Delaware school staff member or a medical professional and interested in learning more about how CCD is supporting these populations at this time?

Yes, I am a Delaware school staff member.Yes, I am a medical professional.No
Client's Name*

First NameMiddle NameLast NameSuffix
Is the client a child?*

YesNo
Parent's Name (If Client is a Child)

First NameMiddle NameLast Name
Chosen Name

First NameMiddle NameLast NameSuffix
Pronouns
Date of Birth/Fecha de nacimiento*

MonthDayYear
Gender
Race
Please note, we can only accept clients located in the states of Delaware and New Jersey
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Number:*
E-mail*
example@example.com
In case of emergency...
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*
Employer (Of Parent if Client is a Child)*
Primary Care Physician:
Name
Phone Number
Does the client have any health problems that we should know about? Please describe below.
Are you on any medications?*

YesNo
If yes, please list it here

Insurance Information

Please answer all questions
Name of Insured*
Date of Birth of Insured*

MonthDayYear
Date
If you have a Social Security #, please enter it here:
Insurance Company*
ID Number*
Please enter your Insurance ID number
Group Number*
Please enter your group number
Employee Assistance Program (EAP)

Please check here if utilizing an EAP and call our office with your authorization number.
Secondary Insurance

If the client has a secondary insurance, please provide the following:
Do you have secondary insurance?*

YesNo
Name of Insured*
Date of Birth of Insured*

MonthDayYear
Date
Insurance Company*
ID Number*
Please enter your Insurance ID number
Group Number*
Please enter your group number
Please read:
Please read:*

By checking this box you agree that you have read and understand the below:
Our current fees are as follows:

Initial Intake Appointment (60 minutes): $160.00
Subsequent Therapy (37- 57 minutes): $135.00
Couples Therapy or Family Therapy (50 minutes): $160.00
If you use your insurance, most insurance agreements require you to authorize us to provide a clinical diagnosis and, sometimes, additional clinical information, such as treatment plans or summaries before they will pay benefits. If your insurance company contacts CCD and requests additional information, we will not release any information without first discussing the insurance request with you. We will obtain your written authorization before releasing any information. Insurance companies claim to keep information confidential, but you should check with your insurance company directly if you have questions about their confidentiality practices. It is important to remember you always have the right to pay for services privately to avoid the issues described above.
Please read:*

Al marcar esta casilla, acepta que ha leído y comprende lo siguiente:
Nuestras tarifas actuales son las siguientes:

Cita inicial de admisión (60 minutos): $160.00
Terapia siguientes (37- 57 minutos): $135.00
Terapia para Parejas o Terapia Familiar (50 minutos): $160.00
Si utiliza su seguro, la mayoría de los acuerdos de seguro requieren que nos autorice a proporcionar un diagnóstico clínico y, a veces, información clínica adicional, como planes de tratamiento o resúmenes antes de que paguen beneficios.

Si su compañía de seguros nos contacta para solicitar información adicional, no vamos a divulgar ninguna información sin hablar primero sobre la solicitud de seguro con usted. Obtendremos su autorización antes de divulgar cualquier información. Las compañías de seguros afirman mantener información confidencial, pero debe consultar directamente con su compañía de seguros si tiene preguntas sobre sus prácticas de confidencialidad.

Es importante recordar que siempre tiene derecho a pagar por los servicios de forma privada para evitar los problemas descritos anteriormente.
Please read:
Please read:
By signing below, you are giving the therapist and CCD permission to bill your insurance company for services. You are also giving the therapist permission to release information necessary to bill insurance company. Your therapist will only release information that is necessary for billing purposes.*

Clear
Al firmar a continuación, le está dando permiso al terapeuta y al CCD para facturar a su compañía de seguros por los servicios. También le está dando permiso al terapeuta para divulgar la información necesaria para cobrarle a la compañía de seguros. Su terapeuta solo divulgará la información necesaria para fines de facturación.*

Clear

Office Policies

Please read and sign below
Please Read Our Office Policies
Please Read Our Office Policies
I have read the Office Policies, I understand them and agree to abide by them. My signature below indicates that I am making an informed choice to consent to therapy (including school-based services for your child, if applicable) and understand and accept the terms of this agreement, including policies on confidentiality (HIPAA), late cancellation and no-show policies, litigation limitations, and informed consent (including telehealth service where applicable).*

Clear
He leído las pólizas de la oficina. Los entiendo y acepto acatarlos. Su firma a continuación indica que está tomando una decisión informada para dar su consentimiento a la terapia y entender y aceptar los términos de este acuerdo.*

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Telehealth Consent Form

Mental Health Services
Are you participating in telehealth (phone, video, computer, etc.) services?*

YesNo
Definition of Telehealth:
Telehealth involves the use of electronic communications to enable CCD clinicians to connect with individuals using live interactive video and audio communications. Telehealth includes the practice of psychological healthcare delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

I understand that I have these rights with respect to telehealth:

1. The laws that protect the confidentiality of my personal information that I have already signed also apply to telehealth. A copy of CCD Office Policies and Therapeutic Informed Consent can be provided to me at my request.

2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care of treatment.

3. I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the counselor, that: the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost of accessed by unauthorized persons.

4. CCD clinicians follow the State of Delaware. They have also received training to provide telehealth services.

5. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented healthcare facility in my immediate area.

Payment for Telehealth Services:

CCD will bill insurance for telehealth services when these services have been determined to be covered by an individual's insurance plan. The standard copay and/or deductible would apply. In the event that insurance does not cover telehealth, you may wish to pay out-of-pocket, or when there is no insurance coverage. We can provide you with a statement of service to submit to your insurance company.

Patient Consent to the Use of Telehealth:

I have read and understand the information provided above regarding telehealth, have discussed it with my counselor, and all of my questions have been answered to my satisfaction. I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the procedure answered. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein. By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.
Definición de Telesalud: Telesalud implica el uso de comunicaciones electrónicas para permitir a los terapeutas de CCD a conectarse con personas utilizando sistemas virtuales de comunicación incluyendo vídeo y audio interactivos. La telesalud incluye la práctica de la entrega de atención psicológica, diagnóstico, consulta, tratamiento, derivación a recursos, educación y transferencia de datos médicos y clínicos.

Entiendo que tengo derechos con respecto a la telesalud:

1. Las leyes que protegen la confidencialidad de mi información personal que ya he firmado

también se aplican a la telesalud. La copia de nuestras políticas de oficina y el Consentimiento Informado Terapéutico puede ser proporcionado.

2. Entiendo que tengo el derecho de retener o retirar mi consentimiento para el uso de la telesalud en el curso de mi cuidado en cualquier momento, sin afectar mi derecho a la atención o tratamiento en el futuro.

3. Entiendo que hay riesgos y consecuencias de la telesalud, incluyendo, pero no limitado

a, la posibilidad, a pesar de los esfuerzos razonables por parte de el/la terapeuta, de que: la transmisión de mi información personal podría ser interrumpida o distorsionado por fallas técnicas, la transmisión de mi información personal podría ser interrumpida por personas no autorizadas, y/o el almacenamiento electrónico de mi información personal podría perderse involuntariamente o accederse personas no autorizadas.

4. Los terapeutas de CCD siguen al estado de Delaware. También han recibido entrenamientos para proporcionar servicios de telesalud

5. Al firmar este documento, estoy de acuerdo en que ciertas situaciones, incluidas las emergencias y situaciones de crisis, son inapropiados para los servicios de psicoterapia por audio/vídeo/computadora. Si estoy en crisis o en una emergencia, debo llamar inmediatamente al 9-1-1 o buscar ayuda de un hospital o un centro de atención orientado a la crisis médica en mi área inmediata.

Pago por Servicios de Telesalud:

CCD facturará el seguro medico para servicios de telesalud cuando se haya determinado que estos servicios son cubierto por el plan de seguro de una persona. Se aplicaría el copago estándar y/o los deducibles.

En caso de que el seguro no cubra la telesalud, es posible que desee pagar de su bolsillo, o cuando no hay cobertura de seguro medico. Podemos proporcionarle una declaración de servicio para enviar a su compañía de seguros.

Consentimiento del Paciente para el Uso de Telesalud:

He leído y entiendo la información proporcionada anteriormente con respecto a la telesalud, he

discutido con mi terapeuta, y todas mis preguntas han sido respondidas a mi satisfacción. He leído este documento cuidadosamente y entiendo los riesgos y beneficios relacionados con el uso de servicios de telesalud y mis preguntas con respecto al procedimiento han sido explicadas.

Por lo presente doy mi consentimiento informado para participar en el uso de los servicios de telesalud para el tratamiento bajo los términos descritos en el presente documento. Por mi firma a continuación, declaro que he leído, y acepto los términos de este documento.
Client's Name*

First NameLast Name
Parent/Guardian's Name (If Client is a Child)

First NameLast Name
Date*

MonthDayYear
Date
Signature

Clear
Firma

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HIPAA/Patient Health Information Notice

Please read and sign below
By signing below you indicate you have read and agree to the above notice:

Clear
Al firmar a continuación, usted indica que ha leído y está de acuerdo con el aviso anterior:

Clear

New Client Registration

Insurance Information

Secondary Insurance

Office Policies

Telehealth Consent Form

HIPAA/Patient Health Information Notice

Problems and Concerns