PLEASE NOTE THAT THE NEW CLIENT PACKET WILL BE AVAILABLE IN JAN 2024. I AM NOT ACCEPTING ANY NEW CLIENTS/BOOKING NEW APPOINTMENTS UNTIL THEN. THANK YOU FOR ALLOWING ME TIME TO
TRANSITION!
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]
Informed Consent For Technology Assisted Counseling Information regarding my office policies and your privacy as impacted by telehealth services are now included in every new intake packet.
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. Informed Consent for Technology Assisted[...] Adobe Acrobat document [135.5 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]
Clinical Nutrition Intake Forms
Symptoms Survey This gives me an idea of which of your bodily systems are being affected, based on your presenting symptoms. SystemsSurveyFormNewEdit2016-Master-2-1-[...] Adobe Acrobat document [245.3 KB]
Stress Assess A brief overview of your current stress levels and stress management strategies. Stress Assess.pdf Adobe Acrobat document [46.9 KB]
Blood Work Request List If you are getting lab work done in the near future, that's awesome. The more information, the better. This is the blood work levels "ideal" list...as many as you can get ordered, the more complete the picture! Blood_Test_List_05145502d8b9de172.pdf Adobe Acrobat document [47.1 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!
Email is the quickest way to connect with me! In order to maintain client privacy, I manage my own schedule which makes it
difficult to field and return phone calls!