Paper work

Client Information

Emergency Contact

Health Information

Religious/Faith Background

Other Information

Acknowledgement of Receipt of
Notice of Privacy Practices & Consent

I have received the office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that i am entitled to receive a copy of this document. (See HIPAA packet included for more details.)

Please READ and SIGN in the spaces provided below:

  • I hereby consent for therapeutic services provided by Las Colinas Counseling Center, P.A.
  • I authorize Las Colinas Counseling Center, P.A. and its agents to release information about me necessary to obtain insurance benefits and/or to receive payment and I understand that my signature requests insurance payments be made.
  • I agree to provide the most up to date insurance information as soon as it is known, and am aware that I will be responsible for balances owed in the event this information is not provided within the insurance’s timely filing parameters.

Spouse & Significant Other Communication: (optional)

Due to HIPAA rules and guidelines we are required to obtain authorization from you in order to provide information Regarding Sheduling & payment to anyone other than yourself. In the event you wish to share information other than scheduling and payment, we require a more detailed release of information form. Please inform your therapist, and/or an administrative staff in the event this is the case.

Please print their name, giving your consent by initialing one or both if you wish to provide your spouse or significant other access to these services.

  • I authorize Las Colinas Counseling Center, P.A. to provide information to:
  • Consent to Email or Text Usage

    For Appointment Reminders and Other Healthcare Communications

    If at any time I provide an email or text address at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information at that email or text address from Las Colinas Counseling Center.

    Please READ and SIGN in the space provided below.

    • I consent to receive text messages from the practice at my cell phone and any number forwarded or transferred to that number or email to receive communication as stated above
    • I understand that this request to receive emails and text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing (please request revocation form from admin staffs).
    • I understand that I can respond to the email or text message to confirm my appointment. I understand that I cannot respond to the electronic communication to cancel or change my appointment.
    • I understand that if I need to cancel I must call the office one day before my scheduled appointment. I understand that failing to respond to the email or text message does not mean my appointment has been cancelled. I understand that I may leave a voice message if I unable to reach the office staff directly.
    • I understand that this is a service offered as a convenience, and understand I am ultimately responsible for any missed appointment fees regardless of whether I receive an electronic reminder or not.

    The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details).

    I have read the office’s Notice of Privacy (HIPAA document) which explains cancellation fees and additional charges outside of my session fees. I understand that I am entitled to receive a copy of this document, and can always obtain a copy when and if needed.