MS, LMFT, BCC
Board Certified Life Coach
FEES FOR SERVICES
(You will be directed to the payment page at the end of this form.)
Note: If necessary, travel expenditures will be charged separately. SERVICES VALID FOR ONE YEAR FROM DATE OF PURCHASE.
ALL SESSIONS ARE NON-TRANSFERABLE.
If you fail to cancel a scheduled appointment, this time cannot be used for another client and you will be billed for the entire cost of your missed appointment. A full session is charged for missed appointments or cancellations with less than 24 hour notice unless due to illness or emergency. Thank you for your cooperation in this matter.
AUTHORIZATION FOR RELEASE OF INFORMATION
To Our Clients
We can help you better if we are able to work with other professionals that know you and your family. By signing this form, you are giving
permission for those listed to share information about your situation.
I authorize the following individuals or agencies to exchange information with Linda Carroll-Barraud, MS, LMFT, BCC:
The information received will be used to better serve in helping in planning and coordinating services for me and my family, or for other
purposes, as specified:
Only information necessary to assist in the process of my care will be exchanged. This permission is good for one year, or until:
I can cancel this at any time, but I understand that the cancellation will not affect any information that was already released before the cancellation. I understand that information about my case is confidential and protected by state and
federal law. I approve the release of this information. I understand what this agreement means. I am signing on my own and have not been pressured to do so.
To Those Receiving Information Under This Authorization
This information disclosed to you is protected by state and federal law. You are not authorized to release it to any agency or person not listed on this form without specific written consent of the person to whom it pertains unless authorized by other laws.
LIMITS OF CONFIDENTIALITY
Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:
Duty to Warn and Protect / when a client discloses intentions or a plan to harm another person, the mental health professional is required
to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide,
the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.
Abuse of Children and Vulnerable Adults / if a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to
report this information to the appropriate social service and/or legal authorities.
Prenatal Exposure to Controlled Substances / mental health care professional are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
Minors/Guardianship / parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.
I agree to the above limits of confidentiality and understand their meanings and ramifications.
Please provide the following information and answer the questions below. Please note: Information you provide here is protected as confidential information.
GENERAL HEALTH AND MENTAL HEALTH INFORMATION
FAMILY MENTAL HEALTH HISTORY
When you are finished, click the REGISTER button below. You will be taken to the payment page.