3519 Paesanos Parkway, Suite 105 Shavano Park, TX 78231

End of Adult Consent Form

Forms

Electronic Form Submission

Informed Consent for
Outpatient Services
&
Notice 0f Privacy Practices

The following form will provide the information necessary to consent, understand our services at GFWC, provides important license information, understand that you have privacy, and that GFWC and yourself have responsibilities. Please be aware that this questionnaire requires sensitive information; as such please be aware of your privacy and complete this in confidential area. Likewise, upon submission of this information; your information is stored in a HIPAA compliant email address that is encrypted and password protected. Please allow 24-72 hours before a Clinician reaches out to assist with your intake via phone or telehealth.

Adult Client Section Only
(no pediatric clients)

By checking this box I consent that I am in a private and confidential area where I can complete this information in private, confidentially, and I am safe to fill this out.

By checking this box I consent that I am an adult of at least 18 years of age and I am legally competent to make my own decions; as such I consent to these services.

Client First Name:

Client Last Name:

Gender acknowledged by health insurance:

Personal Cell Phone

Date of Birth

May we leave a (check all that apply):

Text Reminders/Outreach

Voicemail

Stadard Mail

Today's Date:

Home Address:

Adult Consent Statement:

Informed Consent for Outpatient Services Contract, Notice of Privacy Practices Forms, and the Reschedule, Cancellation, and No-Show PolicyView Forms

Adult Client Signature:

Health Insurance Plan Information (Name, Employer, ID #, Group #, Who is Primary [relationship to client], Ins Phone & Fax):

Please upload your Primary Health Insurance, Identification and any relavent information pertaining to your previous care (Notes, discharge, treatement plans, insurance cards, referral, etc.

Upload File

Pediatric Client Section
(This section is for only children entering care NOT ADULTS)
Please have a Parent or Guardian fill out this Form

By checking this box I consent that I am in a private and confidential area where I can complete this information in private, confidentially, and I am safe to fill this out.

By checking this box I consent I am an adult 18 years of age or older and I am able to consent legally to my child's psychological care as a client. *If you are divorced or there is a formal child custody agreement from a divorce/seperation, foster care, kinship, etc. you will be required to provide those forms prior to receiving care.

Health Insurance Plan Information (Name, Employer, ID #, Group #, Who is Primary [relationship to client], Ins Phone & Fax):

Child's Legal First Name:

First Name:

Parent's Email:

Personal Cell Phone

Child's Legal Last Name:

Last Name:

Date of Birth:

May we leave a (check all that apply):

Text Reminders/Outreach (Required)

Voicemail

Stadard Mail

Gender acknowledged by health insurance:

Home Address:

*Pediatric Consent Statement:

I attest that my child and/or our family is not in the process of a child custody battle. I am the primary guardian listed in the Divorce Decree or Conservatorship Paperwork (Legal Judge Signed) or have equal rights to consent for Psychological Care. If no Legal Paperwork was ever completed, both biological parents must sign this form(s) and be present for the FIRST appointment.View Forms

Informed Consent for Outpatient Services Contract, Notice of Privacy Practices Forms, and the Reschedule, Cancellation, and No-Show PolicyView Forms

Caregiver Signature (A)

Click here if your child has a second caregiver with equal legal right.

First Name:

Parent's Email

Personal Cell Phone

Gender acknowledged by health insurance:

Last Name:

Date of Birth

May we leave a (check all that apply):

Text Reminders/Outreach (Required)

Voicemail

Stadard Mail

Today's Date

Informed Consent for Outpatient Services Contract, Notice of Privacy Practices Forms, Reschedule, Cancellation, and No-Show Policy Forms:View Forms

Caregive Signature (B)

Address:

If same address as above Caregiver (A) leave blank:

Please upload your Child's Primary Health Insurance, Identification and any relavent information pertaining to your child's previous care (Notes, discharge, treatement plans, insurance cards, referral, etc.

Upload File

Informed Consent for Outpatient Services Contract, Notice of Privacy Practices Forms, and the Reschedule, Cancellation, and No-Show PolicyView Forms

Click here to download a copy of your form above

End of Pediatric/Child
Consent Form

End of Adult Consent Form
scroll to the bottom of the page to submit this form.

End of Adult Consent Form

Forms

Electronic Form Submission

Informed Consent for Outpatient Services & Notice 0f Privacy Practices

Adult Client Section Only (no pediatric clients)

Pediatric Client Section (This section is for only children entering care NOT ADULTS) Please have a Parent or Guardian fill out this Form

End of Pediatric/Child Consent Form

End of Adult Consent Form scroll to the bottom of the page to submit this form.

Informed Consent for
Outpatient Services
&
Notice 0f Privacy Practices

Adult Client Section Only
(no pediatric clients)

Pediatric Client Section
(This section is for only children entering care NOT ADULTS)
Please have a Parent or Guardian fill out this Form

End of Pediatric/Child
Consent Form

End of Adult Consent Form
scroll to the bottom of the page to submit this form.