Client Forms

Insurance Verification Form

Download the Insurance Verification Form, fill out and email to us before your first appointment.

Client PACKET

Download the Client Profile Packet, fill out and email to us or bring to your first appointment.

Adolescent Informed Consent Form

Download the Adolescent Informed Consent Form, fill out and email to us or bring to your first appointment.

Telemental Health Informed Consent Form

Download the Telemental Health Informed Consent Form, fill out and email to us before your first appointment.

CONFIDENTIALITY

Information regarding your health care, including payment for health care, is protected by two federal laws: the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C  1320d et seq., 45 C.F.R. Parts 160 & 164 and the confidentiality Law, 42 U.S.C. 290DD-2, 42 C.F.R. Part 2. Under these laws, Chambless Counseling may not say to a person outside Chambless Counseling that you are involved in services with Chambless Counseling, or may Chambless Counseling disclose any information identifying you as someone seeking psychotherapeutic treatment, or disclose any other protected information except as permitted by federal law.  

Chambless Counseling must obtain your written consent before it can disclose information about you. Generally, you must also sign a written consent before Chambless Counseling can share information for treatment purposes or for health care operations.  However, federal law permits Chambless Counseling to disclose some information without your written permission. Details are available during intake sessions.