Client Intake, Consent & HIPAA Compliance Form

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 Client Intake, Consent & HIPAA Compliance Form

Date: ________________

• Full Name: _______________________________________
• Date of Birth: _____________________________________
• Email Address: ___________________________________
• Phone Number: __________________________________
• Preferred Contact Method: ☐ Email ☐ Phone ☐ Text

• Emergency Contact Name: __________________________
• Relationship to Client: ____________________________
• Phone Number: __________________________________

(These questions help tailor services to your needs.)

• Do you have any medical conditions or concerns you’d like me to be aware of?
  ☐ Yes ☐ No (If yes, please describe): ___________________________
• Are you currently seeing a licensed therapist, psychiatrist, or medical professional for mental health or medical concerns?
  ☐ Yes ☐ No (If yes, please provide details as needed): _____________
• Are you currently taking any medications related to mental health or well-being?
  ☐ Yes ☐ No (Optional)

What holistic counseling services are you interested in? (Select all that apply)
☐ Cognitive Behavioral
☐ Solution Focus
☐ Mindfulness & Meditation Guidance
☐ Neurolinguistic Programming & Affirmations
☐ EFT, Emotional Freedom Acupressure Tapping
☐ Self-Hypnosis & Visualization
☐ Energy Clearing & Balancing
☐ Psychic or Intuition Tools
☐ Other (Please specify): ___________________________

What are your primary goals for holistic counseling?

______________________________________________________

______________________________________________________

I understand that:

• Holistic Counseling is not a substitute for medical, psychological, or psychiatric treatment.
• Maria Santos-Ruiz, M.A., previously practiced as a licensed therapist but now chooses to work outside a licensed framework to offer alternative holistic counseling options.
• My sessions are private and confidential, except in cases where disclosure is required by law (e.g., harm to self/others, abuse, neglect, court orders).
• My personal health information (PHI) is protected under HIPAA guidelines and will not be shared without my written consent unless required by law.
• I consent to electronic communication (email, text, phone) and understand the risks involved in transmitting my information through these methods.
• I take full responsibility for my well-being and the choices I make as a result of these sessions.

Client Signature: ________________________
Date: ______________________________

I understand that if I need to cancel or reschedule my appointment, I must provide at least 24 hours’ notice to receive a refund or credit for a future session. Cancellations made less than 24 hours before the scheduled appointment will not be eligible for a refund. Exceptions may be considered in cases of emergency at the discretion of the counselor.

By signing below, I confirm that I have read and understand this consent form. I voluntarily agree to participate in holistic counseling services and accept the terms outlined above.

Client Signature: _________________________ Date: _______________
Counselor Signature: _________________________ Date: _______________

I understand that Holistic Counseling is intended to support overall well-being and personal growth. These services do not replace medical, psychological, or psychiatric treatment. Maria Santos-Ruiz is no longer a licensed medical provider and does not diagnose, treat, or cure medical or mental health conditions. She has chosen to practice outside of a licensed framework to incorporate holistic approaches tailored to client needs.

I acknowledge that my participation in holistic counseling is voluntary, and I accept full responsibility for my choices, actions, and outcomes. I understand that results vary, and no guarantees are made regarding specific benefits.

I release and discharge my holistic counselor from any claims, demands, or legal actions related to my participation in these services. I understand that my counselor is not liable for any perceived or actual harm, loss, or injury arising from these sessions.

I acknowledge that my Personal Health Information (PHI) is protected under HIPAA. My counselor will not share my information unless:

1. Disclosure is required by law (e.g., abuse, harm to self/others, court order).
2. I provide written consent to share information with a third party.
3. It is necessary for administrative or insurance purposes with my permission.

If I experience severe distress, suicidal thoughts, or a medical emergency, I understand that I should seek immediate care from a licensed mental health professional or medical provider. My counselor may also recommend additional professional support when necessary.

I have read, understood, and voluntarily agree to this HIPAA Compliance, Privacy Notice, and Waiver of Liability. By signing below, I confirm that I accept the terms and conditions outlined above.

Client Signature: ___________________________________
Date: _______________
Counselor Signature: _________________________ 

Date: _______________