Informed Consent to Treatment

I am willfully agreeing to enter into treatment to be provided by Teri Sprouse, LCSW.  I have been informed of the nature and expected course of treatment and of possible limitations.  I understand that I will be informed of any change in treatment and that I may revoke consent at any time without reprisal.

I have been informed of my right to a confidential relationship within specified limits.  I understand that information divulged in the context of treatment will not be shared with others without my expressed written permission except in cases of abuse or potential danger to myself or others.  These may include any statement I make of intent to commit suicide or homicide, statements indicating that I have committed, or intend to commit, acts of child or elder/disabled adult abuse, or in the case of a medical or other emergency which would necessitate disclosure of relevant information to facilitate further treatment.  I also understand that pertinent information may be disclosed for the purposes of third-party billing and for collecting past due fees (i.e. through a collection agency).  In the latter case, this action will be taken only after I have received a written warning.  I further understand that if I choose to communicate by email, that they are not fully confidential in that they may be stored on email servers or other computer systems.

My signature below indicates that I have read the above statement and  received a copy of the HIPAA Notice of Privacy Practices.  I understand and agree to enter into treatment/assessment under these conditions.  I have had the opportunity to ask questions about the policies and HIPAA privacy notice, and have had those questions answered to my satisfaction.

I may revoke this agreement in writing at any time. That revocation will be binding except for: 1) actions already taken on the agreement before it was revoked; 2) unpaid financial obligations; or 3) if there are obligations imposed by your health insurer in order to process or substantiate claims.


Client’s name (please print)

_______________________________________________              _________________

Client’s signature (or legal guardian)                                                        Date

_______________________________________________              _________________

Teri Sprouse, LCSW                                                                                        Date

Licensed Clinical Social Worker
















Client Information:




Zip Code___________________________Work Phone_____________________________

Phone________________________________________ Cell________________________

Is it okay to leave messages at these phone numbers?______________________________


Is it okay to send e-mails to this email address?______________________________________

Referred by_________________________________________________________________

Personal Information:

Age______________________________Date of Birth________________________________

Insurance Company ______________________________________________________________


Emergency contact name and phone number:_______________________Relationship______________











Billing and Cancellation

Payment is due at the time of service.  If you are using an insurance benefit to pay for services, please review your policy thoroughly with that company. If I am a contracted provider, I will automatically submit claims on your behalf. Co-payments can be made at each session by cash, check, or credit card.

Insurance: My contract for professional services and payment is with you. Your counseling services may be partially covered by a behavioral health provision in your health insurance policy or some other third party payer (i.e. Victim’s Assistance Fund). I will only bill directly those plans for whom I am a designated provider. Mental health insurance coverage differs dramatically from one company to another, and change from year to year. It is often difficult to predict the services and fees different plans will cover. It is important that we discuss these issues in your early sessions, or when there is a change in policies, to avoid confusion and problems that could interfere with our work together. Please keep in mind any deductible that requires you to cover services, especially at the beginning of the year.

Appointments: Your appointment is held exclusively for you. If you are unable to keep your appointment or need to reschedule, please call my office at least 24 hours in advance. Otherwise, you will be charged $35 for the session (insurance does not pay for missed appointments). Late fees in situations where you are unable to give 24 hours notice will be considered on a case by case basis.

Emergencies: In case of an urgent situation, please leave a message for me on my office voice mail.  I check for messages several times during each work day, and will return your call as soon as possible. If you need immediate attention, call Multnomah County Crisis Line at 503 988 4888. In the event of a life threatening or extreme emergency, call 911 or go directly to the nearest emergency room.

My signature below indicates that I have reviewed and understood these policies.


___________________________________________________ date________________








 HIPAA Statement

 Summary Notice of HIPAA Privacy Practices


The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the Patient, significant rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

We have prepared this “Summary Notice of HIPAA Privacy Practices” to explain how we are required to maintain the privacy of your health information and how we may use and disclose your health information. A Notice of HIPAA Privacy Practices containing a more complete description of the uses and disclosures of your health information is available to you upon request.

We may use and disclose your medical records for each of the following purposes: treatment, payment, and health care operations:

TREATMENT means providing, coordinating, or managing health care and related services by one or more health care providers.

PAYMENT means such activities as obtaining payment or reimbursement for services, billing or collection activities and utilization review.

HEALTH CARE OPERATIONS include managing your Electronic Medical Record to facilitate diagnostic medical consultations with participating physicians, as well as conducting quality assessment and improvement activities, auditing functions, cost-management analysis and customer service.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide information about our services or other health-related services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the DocLogic Privacy Officer:

You have the right to ask for restrictions on the ways we use and disclose your health information for treatment, payment and health care operations. You may also request that we limit our disclosures to persons assisting your care. We will consider your request, but are not required to accept it.

You have the right to request that you receive communications containing your protected health information from us by alternative means or at alternative locations. For example, you may ask that we only contact you at home or by mail.

Except under certain circumstances, you have the right to inspect and copy medical, billing and other records used to make decisions about you. If you ask for copies of this information, we may charge you a nominal fee for copying and mailing.

If you believe that information in your records is incorrect or incomplete, you have the right to ask us to correct the existing information or add missing information. Under certain circumstances, we may deny your request, such as when the information is accurate and complete.

You have a right to receive a list of certain instances when we have used or disclosed your medical information. If you ask for this information from us more than once every twelve months, we may charge you a fee.


Client Signature        ______________________________________ Date


Therapist Signature  ______________________________________ Date





































Please mark each symptom you experience:

  1. Feeling worried more days than not about a number of subjects like  school, work, etc
  2. Feeling sad more days than not.
  3. Feeling it is hard to control the worry
  4. Feeling restless or key up.
  5. Feeling easily fatigued or tired.
  6. Difficulty concentrating or feeling like your mind is going blank.
  7. Feeling grouchy or easily annoyed.
  8. Feeling muscle tension.
  9. Difficulty falling or staying asleep.
  10. Not feeling hungry or eating more than normal.
  11. Sleeping more or less than normal.
  12. Feeling hopeless.
  13. Difficulty making decisions.
  14. Feeling guilty.
  15. Feeling worthless.
  16. Frequent thought of death or suicide.









If you wish, you may pay fees electronically with the use of Square Credit Card and/or Apple Pay Processing Services.

Please Be Aware of the Following:
I have a duty to uphold your confidentiality, and thus I wish to make sure that your use of the above payment services is done as securely and privately as possible.

After using any of the above services to pay your fees, that service may send you receipts for payment by email or text message. These receipts will include my business name, and would indicate that you have paid for a therapy session.

It is possible the receipt may be sent automatically, without first asking if you wish to receive the receipt. I am  unable to control this in many cases, and I may not be able to control which email address or phone number your receipt is sent to.

So before using one of the above services to pay for your session(s), please think about these questions:

  1. At which email address or phone numbers have I received these kinds of receipts before?
  2. Are any of those addresses or phone numbers provided by my employer or school? If so, the employer or school will most likely be able to view the receipts that are sent to you.
  3. Are there any other parties with access to these addresses or phone numbers that should not be seeing these receipts? Would there be any danger if such a person discovered them?In addition to these possible emails or text messages, payments made by credit card will appear on your credit card statement as being made to Teri Sprouse, LCSW. Please consider who might have access to your statements before making payments by credit card.
    Health Savings Accounts and Flexible Spending AccountsIf you are using a Health Savings Account (HSA) or Flexible Spending Account (FSA) payment card, please be aware that even if your payment goes through and is authorized at the time that we run your card, there is a possibility that your payment could later be denied. In the event of this happening, you are responsible for ensuring that full payment is made by other means.

I understand the risks in using electronic payment methods.



Signature: ____________________________________ Date:________________________




It may become useful during the course of treatment to communicate by email, text message (e.g. “SMS”) or other electronic methods of communication. Be informed that these methods, in their typical form, are not confidential means of communication. If you use these methods to communicate with me, there is a reasonable chance that third party may be able to intercept and eavesdrop on those messages. The kinds of parties that may intercept these messages include, but are not limited to:

* People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages

* Your employer, if you use your work email to communicate with me.

* Third parties on the Internet such as server administrators and others who monitor Internet traffic.



I consent to allow Teri Sprouse, Wholistic Nutritionist, LCSW to use unsecured email and mobile phone text messaging to transmit to me the following Protected Health Information:

• Follow up information including recommendations, additional information, recipes and goals from our work together

• Information related to the scheduling of meetings or other appointments

• Information related to billing and payment

I have been informed of the risks, including but not limited to my confidentiality in

treatment, of transmitting my Protected Health Information by unsecured means. I

understand that I am not required to sign this agreement in order to receive treatment.

I also understand that I may terminate this consent at any time.  My signature below indicates consent for Teri Sprouse, Wholisitic Nutritionist, LCSW to use electronic communication in our work together.

______________________________________________ _____________________

Client Name

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