Forms For Clients
New Client Packet
All form needed for an in-office visit that does not include any nutritional assessments.
New Client Packet Packet 2022.pdf
Adobe Acrobat document [550.8 KB]
All form needed for an in-office visit that does not include any nutritional assessments.
New Client Packet Packet 2022.pdf
Adobe Acrobat document [550.8 KB]
Minor Client Consent Waiver
If you are under the age of 18 and seeking mental health counseling services, Texas statelLaw (Texas Family Code, Section 32.004) requires that a parent or guardian grant permission for treatment with certain exceptions. If you are seeking treatment without parent or guardian permission because one of these exceptions apply, please include this form with your intake packet.
Minor Client Consent Waiver.pdf
Adobe Acrobat document [81.1 KB]
If you are under the age of 18 and seeking mental health counseling services, Texas statelLaw (Texas Family Code, Section 32.004) requires that a parent or guardian grant permission for treatment with certain exceptions. If you are seeking treatment without parent or guardian permission because one of these exceptions apply, please include this form with your intake packet.
Minor Client Consent Waiver.pdf
Adobe Acrobat document [81.1 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]
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]
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]
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]
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]
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]
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]
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]
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]
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]
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!
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