ROI | Arttherapyalchemy

Release of Information (ROI)

*This form is for current clients.

If you give consent to "release information", you are asking and approve me, Emily Taylor, ATR-BC, LPCC, to the following:

(1) collaborate with your current or past provider at your request, and

(2) allows me to access your primary Diagnostic Assessment (DA) from your previous/ current clinician.

It is totally within your right to refuse consent here, and I completely respect that choice! Please tell me know if you have any questions. Thank you.

Terms:

What is a DA? Diagnostic Assessments and materials are key information for me to have, and saves us from a lengthy intake session. I am always open to skipping this aspect of therapeutic care (either a DA or Intake Session), but please note your level of care will not be as well rounded on the onset and will instead be unearthed over time.

What if I want you to write a DA for me? You can choose to have me do a new DA for you, with diagnosis included, for a flat 200$ fee. Many find this helpful. You will have access to this Assessment via PDF.

What is collaboration? Collaboration is part of offering a high level of care, which every client deserves. It is considered part of ethical practice. And essential if you'd like me to work with your other counselor(s).

Note: This form is HIPAA compliant.

Authorization for Release of Confidential Information and/or Collaboration

Client Information

Enter the following information about yourself (the client).

First & Last (Legal) Name

Birthdate

Message (What I need to know about this connection/ what you'd like to happen with our collaboration)

Your clinician you wish Emily to coordinate with:

Clinician Name + Company / Location

Position

Clinician or Clinic Email

Clinician or clinic Phone + Fax

By signing I understand the following:

This request is entirely voluntary on my (the client's) part.
I understand that I may take back this consent at any time within 12 months, except to the extent that action based on this consent has been taken or State mandated reporting rules are engaged.
I agree to ask Emily or my other clinician(s) any questions I may have.
I understand I can refuse this document at any time, consent is completely within my power.

I, the client, authorize release of information and records to Emily Taylor, Art Therapy Alchemy on for ongoing services.

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking the above box you agree to hold ATA harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Release of Information (ROI)

Authorization for Release of Confidential Information and/or Collaboration

Thank you for your time! Looking forward to giving you even more support;

©2023 Emily Taylor, MA, ATR-BC, LPCC