Client Forms

Client forms are available to electronically sign through your portal at Therapy Portal.

Informed Consent – This form outlines important policies and business practices and must be signed prior to starting treatment.
Running Therapy Informed Consent – This form outlines additional policies and practices as related to in-person running therapy and must be signed prior to starting running therapy.
Rights and Responsibilities – Outlines therapist and client rights and responsibilities.
Non-Secure Electronic Communications Informed Consent – This form is available to those who, after reviewing the risks of using non-secure electronic communication forms, are choosing to use standard email and/or text as a means of communication with the therapist.

Payment Authorization – This form authorizes the therapist to bill for services.
Payment Authorization – Responsible Party for Billing – This form authorizes the therapist to bill someone other than the identified client for services.
Client Insurance Form – In-Network – This form authorizes the therapist to bill client’s in-network insurance.
Client Insurance Form – Superbill Out-of-Network – This form authorizes the therapist to share information with client’s out-of-network insurance to substantiate reimbursement if requested.
Client Insurance Form – Courtesy Bill Out-of-Network – This form provides authorization for therapist to bill client’s out-of-network insurance.

Notice of Privacy Practices 2-16-2016 – Information about the Health Insurance Portability and Accountability Act (HIPAA). Signing this acknowledges that you have received the notice.
Release of Information – Authorizes the therapist to disclose and/or obtain information from a person/entity, usually for the purpose of coordination of your care.
- Release of Information – Emergency Contact Sample
- Release of Information – Prescriber Sample