New Client Paperwork (Adolescents)

Client Information, Informed Consent, and HIPAA Agreement
(for Children/Adolescents)

Please complete this form and click "submit" at the bottom.

* Indicates required field

Full Name: *

Address: *

City: *

State: *

Zip Code: *

Phone Number: *

Email: *

Date of Birth: *

Age: *

Do you attend school? If so, what grade are you in? *

Emergency Contact Information (will ONLY be used in case of an emergency):

Emergency Contact's Name: *

Emergency Contact's Number *

In your own words, what would you say is going on, or what is the problem as you see it? Why have you decided to come to therapy, and why at this particular time? *

Confidentiality

When you meet with a therapist, everything we talk about is confidential, which means that it "doesn't leave the room." This means that I will not tell anyone anything that you say to me. BUT, it's important for you to know there are a few exceptions to this rule. I will not tell anyone anything that you say to me UNLESS it falls into one of these categories:
1) You let me know you are thinking about or planning to hurt or kill yourself,
2) You let me know you are thinking about or planning to hurt or kill someone else,
3) You let me know that someone is hurting or abusing you, or
4) You let me know that someone is hurting or abusing someone else (child, elderly person, or someone with special needs).

By signing below, you are stating that you understand what "confidentiality" means, and the few exceptions to this rule.

Do you understand what "confidentiality" means, and the few exceptions to the rule? *

Yes

Signature *

Date *

Submit

New Client Paperwork

​Confidentiality

Dr. Shannon Francom, LMFT-Sand Associates

Confidentiality

Dr. Shannon Francom, LMFT-S
and Associates