Private Practice Forms
for Professional Counselors
Save yourself the time and money required to create your own private practice forms from scratch! Private Practice Forms for Professional Counselors includes 13 ready-to-adapt forms (totaling 29 pages) and have been updated for 2022. These forms will provide a basis for building agreement with clients as it relates to your services and receiving payment for those services. They can also serve as an important part of your administrative record-keeping.
The following forms are included:
• Professional Disclosure Statement and Informed Consent for Counseling Services: provides the client with relevant information about, risks and benefits of, and alternatives to counseling services; includes sections on counselor approach, training, and scope of practice, “what to expect”, alternatives to therapy, client rights, privacy and confidentiality issues, policies regarding appointments, communication, and payment, and the use of physical touch in counseling.
• Informed Consent for Online Counseling Services: provides the client with relevant information about, risks and benefits of, and alternatives to online counseling services.
• Informed Consent for Limitations on Confidentiality in Relationship Counseling: provides the client with information about the limits of confidentiality in the context of relationship counseling (i.e. a “no secrets” policy).
• Informed Consent for Group Counseling Services: provides the group member with relevant information about, risks and benefits of, and alternatives to group counseling services.
• Private Payment Agreement: establishes a private payment agreement with a client who is not pursuing insurance reimbursement.
• Consent to Assume Responsibility for Payment of Counseling Services (Private Payment): establishes a payment agreement with someone who is not the client but who is assuming responsibility for payment of counseling services (e.g. a parent) and not pursuing insurance reimbursement; the payer should also be provided with copies of the documents referenced within this form.
• Out-of-network Insurance Use and Payment Agreement: establishes a payment agreement with a client pursuing out-of-network insurance reimbursement.
• Consent to Assume Responsibility for Payment of Counseling Services (Out-of-network): establishes a payment agreement with someone who is not the client but who is assuming responsibility for payment of counseling services (e.g. a parent) and pursuing insurance reimbursement; the payer should also be provided with copies of the documents referenced within this form.
• Adult Intake Questionnaire: provides the counselor with the client’s demographic information and, for the purposes of assessment and case conceptualization, information about their biological, psychological, and sociocultural functioning.
• Risks of Nonsecure Communication: informs the client of the risks associated with communicating with the counselor by nonsecure means.
• Release and Permission to Record Counseling Sessions and to Use Case Materials: grants permission to the counselor to record counseling sessions for use in consultation and obtaining supervision, and/or in the training and providing of supervision to other mental health professionals.
• Authorization to Use and Disclose Protected Health Information: authorizes therapist to use and disclose client health information to another person or organization, typically for the purposes of coordinating care or referral.
• Consent for Collateral Participation: informs the collateral participant of their role as a collateral ally in the client’s counseling process and obtains permission from the client for the collateral ally’s participation.
These are the forms that I use in my own practice. The information contained in these forms reflect Oregon state laws and rules, the American Counseling Association Code of Ethics, and the needs of my own clients and practice. They are most appropriate for counselors working with adults and building a private pay practice. This packet does not include forms specific to working with minors nor HIPAA-related forms. You’ll need to modify forms in this packet so that they are in compliance with your own state laws and rules and professional organization’s codes of ethics and guidelines, and to reflect the needs of your own clients and your own practice. Sections that most clearly need modification have been highlighted. If you’re attempting to become fully compliant with HIPAA federal regulations, you’ll need to acquire additional forms. For that, I recommend purchasing the latest edition of the HIPAA Compliance Kit by Ofer Zur, PhD and Roy Huggins, LPC.
Ordering Information and Refund Policy
Private Practice Forms for Professional Counselors is available as a single Microsoft Word document (for Windows or Mac) and is delivered by digital download. Once your purchase has been approved, you’ll receive a confirmation e-mail that contains the link you need to download this document. To prevent unauthorized distribution, sharing, or transferring of this product, this link is accessible only once. Once you’ve modified the forms, you can print hard copies or PDF versions of individual forms directly from the Microsoft Word file, and/or copy them into the forms section of your EHR. Because the forms are delivered by digital download, I’m unable to offer refunds, but please do get in touch if I can help you with your order in any way.
Lastly, purchasing these forms grants you access to a private Facebook group for additional support from Ryan and other practitioners in private practice. The link for joining this group will be included in your order confirmation e-mail.