Intake Forms
Intake Forms
Choose 1 appropriate Intake form:
| Adobe PDF | Microsoft Word Document |
| Intake Adolescent | Intake Adolescent |
| Intake Child | Intake Child |
| Intake Adult | Intake Adult |
Review these:
Sorry for there being so much. This is the way the legal world is moving...and I must go with the flow...
| Adobe PDF | Microsoft Word Document |
| Informed Consent | Informed Consent |
| Consent for Text & Email | Consent for Text & Email |
| Notice of Privacy Practices | Notice of Privacy Practices |
| Adobe PDF | Microsoft Word Document |
| Family Therapy Consent | Family Therapy Consent |
Instructions:
- Click on a form to download. Choose either pdf or Microsoft Word format. The Word documents are fillable. If needed, you may download Adobe Reader to read the pdf
- You must have Microsoft word, or an equivalent to read and edit the Word documents.
- Bring completed forms to your appointment.
- If you prefer to submit a form electronically, you may do so. Please email me and I will reply to you with a form which allows you to do so privately and securely.
Other Forms
Other Forms:
| Adobe PDF | Microsoft Word Document |
| Release of Information - Adult | Release of Information - Adult |
| Release of Information - Minor | Release of Information - Minor |
Instructions:
- Click on a form to download. If needed, you may download Adobe Reader to read the pdf. You must have Microsoft word, or an equivalent to read and edit the word documents.
- Bring completed forms to an appointment.
- If you prefer to submit the form electronically, email me and I will reply with a form that permits you to do so privately and securely.
Notice of Privacy Practices
Notice of Privacy Practices
Although I am NOT a HIPAA covered entity, I am complying with these HIPAA standards.
Federal legislation (HIPAA, the Health Information Portability and Accountability Act) requires that all organizations or practitioners who store or transmit client personal health information in electronic form, comply with HIPAA. While some of the rights listed may not legally appy, I am happy to comply with normal requests. This includes a responsibility to develop policies and procedures to protect your information and requires practitioners to inform clients of their privacy practices. These practices must meet complex legal standards. This Notice of Privacy Practices provides you with that information, and informs you of your rights and our responsibilities, in compliance with HIPAA rules and regulations:
Disclosure of psychotherapy notes is usually excluded from HIPAA disclosures. In general, if requested my policy is to provide a treatment summary if requested, and I may also limit disclosures as permitted by State and Federal law.
You may download a copy of this Notice of Privacy Practices in either pdf or Microsoft Word formats:
| Adobe PDF | Microsoft Word Document |
| Notice of Privacy Practices | Notice of Privacy Practices |
Notice of Privacy Practices
Russell Hendlin, LMFT
MFC 25562
P.O. Box 189
415 233-0788
San Geronimo, CA 94963
This email address is being protected from spambots. You need JavaScript enabled to view it.
Privacy Officer: Russell Hendlin
- Your information
- Your rights
- Our Responsibilities
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
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Get an electronic or paper copy of your medical record |
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Ask us to correct your medical record |
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Request confidential communications |
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Ask us to limit what • You can ask us not to use or share certain health information for treatment, we use or share payment, or our operations.
- We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
- We will say “yes” unless a law requires us to share that information.
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Get a list of those with whom we’ve shared information |
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Get a copy of this privacy notice |
• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. |
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Choose someone to act for you |
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File a complaint if you feel your rights are violated |
Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting |
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www.hhs.gov/ocr/privacy/hipaa/complaints/.
Your Choices:
For certain health information, you can tell us your choices about what we share.
If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
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In these cases, you have both the right and choice to tell us to: |
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. |
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In these cases we never share your information unless you give us written permission: |
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Our Uses and Disclosures:
How do we typically use or share your health information? We typically use or share your health information in the following ways.
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Treat you |
• We can use your health information and share it with other professionals who are treating you. |
Example: A doctor treating you for an injury asks another doctor about your overall health condition. |
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Run our organization |
• We can use and share your health information to run our practice, improve your care, and contact you when necessary. |
Example: We use health information about you to manage your treatment and services. |
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Bill for your services |
• We can use and share your health information to bill and get payment from health plans or other entities. |
Example: We give information about you to your health insurance plan so it will pay for your services. |
How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
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Help with public health and safety issues |
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Do research |
• We can use or share your information for health research. |
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Comply with the law |
• We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. |
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Respond to organ and tissue donation requests |
• We can share health information about you with organ procurement organizations. |
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Work with a medical examiner or funeral director |
• We can share health information with a coroner, medical examiner, or funeral director when an individual dies. |
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Address workers’ compensation, law enforcement, and other government requests |
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Respond to lawsuits
• We can share health information about you in response to a court or legal actions
Our Responsibilities
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available on request in our office and will be posted on our website at Hendlin.org.
Effective 3/1/2019