Celebrating 10 Years

Online Counseling Intake

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Client Intake Form

Please read all information pertaining to limits if confidentiality, insurance and cancellation policy before proceeding to the online intake form provided below. 

Limits of Confidentiality

Confidentiality between client and therapist is of the utmost importance. Your verbal communication and clinical records are strictly confidential except for the following:

  1. Information you and /or your child or children report about physical of sexual abuse of a minor or an elder person; in such cases I am obligated by Connecticut State Law to report this information to the CT Department of Children and Families.
  2. If you provide information that informs me that you are in danger of harming yourself of others.
  3. Where you sign a release to have specific information shared.
  4. Information shared with your insurance company to process your claims.

Telehealth and Online Counseling

Telehealth involves the use of electronic communications to enable West Hartford Holistic Counseling clinicians to connect with individuals using live interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the authorized transfer of medical and clinical data.

I understand I have the rights with respect to telehealth, including:

  1. The laws that protect the confidentiality of my personal information that I have already signed also apply to telehealth. Copy of our Office Policies and Therapeutic Informed Consent can be provided.
  2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
  3. I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. WHHC utilizes secure, encrypted HIPAA compliant audio/video transmission software to deliver telehealth via Doxy.Me.
  4. WHHC clinicians follow the State of Connecticut Regulations for tele-health: as well as their respective board regulations (BOPC/ACA or BSWE/NASW) and ethics. They have also received training to provide tele-health services.
  5. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

I understand and agree to the above limits of confidentiality and rights with respect to telehealth, their meanings and ramifications, and acknowledge the electronic signature affixed below carries the full weight of my handwritten signature.

Cancellation Policy

Appointments cancelled less than 24 hours before the scheduled appointment time, or missed altogether, are subject to a cancellation fee equal to the amount of a full fee appointment. The amount due will be charged to the credit card on file.

You will be asked to provide credit card information for our files below.


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