• I, (client name)
  • I understand that these services may be in the form of Therapeutic Interventions, Assessment, Treatment Planning, and Psychiatric Services.

    I also understand that all clinical information will be kept confidential, except as stipulated in Florida Statutes 39, 394 and the Health Insurance Portability and Accountability Act as described in the Privacy Notice. The clinical record is the property of and will be retained by HEADS.

    Only authorized personnel of HEADS may review my clinical record for the purpose of clinical provision, supervision, consultation, auditing, compliance, and billing. Portions of my information will be provided to my insurance company to be used for billing and payment purposes. This notice will be kept for a period of eight (8) years.

    I acknowledge receipt of HEADS Clients Rights and Responsibilities. I have been given the opportunity to ask questions and I understand my rights and responsibilities. I have been informed by HEADS’s staff of the services available through HEADS and agree to participate.

    I may revoke my consent in writing for any or all services at any time.