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

Forms For Clients

Life History Questionnaire
Just to tell me a little bit about yourself!
Life History Questionnaire.pdf
Adobe Acrobat document [217.1 KB]
Counseling Contract
Contract for counseling and wellness services for new clients.
Counseling Contract with Faith Harper_20[...]
Adobe Acrobat document [143.7 KB]
Contact Information Form
Preferred means of contact with Faith Harper regarding counseling services.
Contact Information Faith Harper.pdf
Adobe Acrobat document [79.6 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]
Receipt of Notification of Privacy Practices
Upon reading the notification of privacy practices (available above), please indicate your receipt of them with this form. Please do not hesitate to ask any questions you may have before signing or at any other point.

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.
Receipt of Notice of Privacy Practices F[...]
Adobe Acrobat document [201.2 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]
Social Media Acknowledgement Form
Form indicating acknowledgement and understanding of my social media policy. Please do not hesitate to ask me any questions you may have before signing the form, or at any point after.
Social Media Acknowledgement Form.pdf
Adobe Acrobat document [209.6 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

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]
Consent To Release Information
Whether I need to coordinate care with your other treatment provider(s) or you wish me to share information with anyone else in the community, I utilize the consent to release information form developed by the State of Texas, designed to address all relevant state and federal privacy laws.

Should you wish to revoke your consent, you may do so at any time. I will honor a verbal request immediately, and will document so in your records, but will also ask for written documentation of your request to revoke consent as well. This form is available below.
Release of PHI.pdf
Adobe Acrobat document [205.3 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]

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)

 

 

Print Print | Sitemap
© Faith G. Harper

This website was created using 1&1 MyWebsite.