Faith G. Harper, PhD, LPC-S, ACS, ACN
Faith G. Harper, PhD, LPC-S, ACS, ACN

Forms For Clients

New Client Packet
All form needed for an in-office visit that does not include any nutritional assessments.
New Client Packet In Office.pdf
Adobe Acrobat document [431.7 KB]
New Client Packet (Plus Nutrition Assessments)
All the forms needed for an in-office for any individuals also want a nutrition assessment provided as part of their services.
New Client Packet In Office Plus Nutriti[...]
Adobe Acrobat document [546.5 KB]
New Client Packet For Distance Counseling Services
If I am providing you services through technological means (video, chat, or phone counseling), please complete this packet and return to me before your first appointment.
New Client Packet Distance Counseling.pd[...]
Adobe Acrobat document [548.0 KB]
New Client Packet For Distance Counseling Nutrition Mini-Session
If you are only receiving a 30 minute nutrition assessment distance counseling mini-session, please complete and return this packet at least 48 hours before your scheduled appointment.
New Client Packet Distance Counseling Nu[...]
Adobe Acrobat document [662.8 KB]
Notice of Privacy Practices: Information about State and Federal Privacy Protections
Your privacy is of utmost importance to me. This information sheet covers federal privacy regulations as well as regulations for the State of Texas.

You do not need to print a copy of this notification before your first appointment, but please do take the time to read it before signing the acknowledgement form listed below. You certainly may print a copy for your records at any time, requested a printed copy at the office, or download it and read it from my website.

This notification may be changed periodically to reflect changes in state and federal privacy laws. If changes are made, you will be given a copy of the updated form with the opportunity to sign a new acknowledgement form before your next appointment.
Privacy Practices Faith Harper_2017.pdf
Adobe Acrobat document [738.9 KB]
Social Media Policy for Faith Harper
My social media policy for new, existing, or former clients.

You do not need to print a copy of this notification before your first appointment, but please do take the time to read it before signing the acknowledgement form listed below. You certainly may print a copy for your records at any time, requested a printed copy at the office, or download it and read it from my website.
Social Media Policy Faith Harper.pdf
Adobe Acrobat document [241.4 KB]
Walk and Talk Therapy
Should you be interested in participating in "walk and talk therapy," this form covers some of the possible risks and will also need to be completed before we schedule a walk and talk session.
Walk and Talk Therapy Waiver.pdf
Adobe Acrobat document [46.8 KB]

Referral Forms and Release of Information Forms

Consent To Release Information
Please complete this form for every individual you want me to be able to communicate with regarding your services. This may include other care providers, family members, etc.
Consent To Release Info Non EMR Version.[...]
Adobe Acrobat document [64.7 KB]
Revocation of Consent To Release Information
Should at any point, you wish to revoke your consent to release information, you can do so using this form.

I will honor a verbal request immediately, and document this information in your records, but will also ask for this form to be completed for my records, as well.
Release of PHI.pdf
Adobe Acrobat document [205.3 KB]
Referral Form To Faith Harper
Many times, I receive referrals from other treatment providers, including medical and mental health professionals. My ethical codes require that in certain instances I maintain contact with these other professionals to discuss our collaborative treatment.

If you and your treatment provider have discussed including me on your treatment team, you may use this form to apprise me of the referral, along with the consent to release information so I can discuss your treatment with the provider in question.
Referral Form to Faith Harper.pdf
Adobe Acrobat document [218.2 KB]
Clinical Consultation Contract
If you are a treatment provider who wishes to consult with me, feel free to email to discuss whether or not the support you are seeking is within my scope of practice. If we determine that I can be of assistance to you, please complete this form prior to our consultation session.
Clinical Conultation Contract.pdf
Adobe Acrobat document [53.6 KB]

All my worksheets are now available under the "Worksheets and Printables" tab at the top of the page!

     Contact Me

Phone: 210-705-2121

Fax: 210-568-4816

 

Please be aware that I use a fax to email service that will convert faxed documents to a PDF format and send them to my office email.

 

Email:

info@faithgharper.com

 

Twitter:

@TheIntimacyDr

and

@SSRPress

 

Facebook Pages: TheIntimacyDr

and

Holhkunna Health

and

Say Something Real Press

 

Other Websites:

TheIntimacyDr.com

and

SaySomethingRealPress.com

 

 

 

Office Address:

8603 Crownhill Suites 3 and 29

San Antonio, TX 78209

The CID Building

(behind Taco Palenque and The Magic Time Machine)

 

 

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