Secure · HIPAA-compliant · Private
Client Forms
Online concierge therapy throughout Florida
HIPAA-Secure Forms for Therapy
All forms on this page are HIPAA-secure. Please note that you will need to log into your Google account to view some of these forms. This is a security measure. If you do not have a Google account, please be advised that you will need one to receive therapy services with my therapy practice. It is free to set up a Google account.
Preliminary Intake Form
Use this form to start the therapy process. Please note that you will need to log into a Google account to view this form. This is a security measure. If you do not have a Google account, please be advised that you will need one to receive therapy services with my therapy practice. It is free to set up a Google account.
Identity Confirmation Form
Complete this form during the intake process before you begin therapy. Identity confirmation is required by law. It’s an important step in protecting your personal health information.
Good Faith Estimate Receipt
Please complete this form to confirm that you received a good faith estimate of the cost of services. Details about the good faith estimate can be found on the therapy services and fees page.
Treatment Plan Receipt Acknowledgement
Please complete this form when you receive a new treatment plan(s) or when we discuss changes to your treatment plan(s).
Authorization for Disclosure and Release of Confidential Information from Client
Complete this form if you are the client and you want me to share any or all of your records with you or a third party, or if you want me to speak with someone other than you about your case. (Attorneys, please ask your client to complete this form before you contact me.)
Revocation of Authorization for Disclosure and Release of Confidential Information from Client
Complete this form if you are the client and you wish to revoke a prior release of information that you signed with Michelle Robin Gould, LMHC and the Michelle Robin Gould Corporation.
Authorization for Disclosure and Release of Confidential Information from Client Representative
Complete this form if you are the client's legally designated personal or legal representative (client’s health care surrogate, estate executor, parental guardian, legal guardian, or person with client’s power of attorney) and you want me to share any or all of the client's records with you or a third party, or if you want me to speak with someone other than you about the client's case.
Revocation of Authorization for Disclosure and Release of Confidential Information from Client Representative
Complete this form if you are the client's legally designated personal or legal representative (client’s health care surrogate, estate executor, parental guardian, legal guardian, or person with client’s power of attorney) and you wish to revoke a prior release of information that you or the client signed with Michelle Robin Gould, LMHC and the Michelle Robin Gould Corporation.
Records Request Form
Complete this form when you need to request a copy of client records, whether you are the client or a third party. Note that requests for records to be sent to third parties must be either requested or authorized by the client via the relevant form. Please see my records request policies and procedures for additional information.
Financial Agreement with Third Party Payor (Financially Responsible Party)
Complete this form if you are not the client but intend to be the financially responsible party paying for the client's therapy services. Please do not complete this form unless the client has sent me a release of information to speak with you regarding their presence in treatment. If they have not, I will not respond to your form submission. HIPAA law does not permit me to acknowledge that someone is/is not a client unless I have a release from them.
Collateral Consent Form: Guidelines for Collateral Sessions, Interviews, and Contact
This form should be completed by collaterals only after the client has completed the form titled Authorization for Disclosure and Release of Confidential Information.
Acknowledgement of Policy Addendum
Complete this form if you received notice of a change to one or more of the practices, policies, and procedures of my psychotherapy services, aka terms of service.
Change of Appointment Request
Use this form when you need to reschedule an appointment. Please be mindful of the cancellation policy, which you can review on my appointments and cancellations page.
Changes to Contact Information
Use this form to let me know when there's a change to your name, address, cell phone, home phone, work phone, or email address, or a change to the contact information for your emergency contact.
Select Secure Method of Transmission of Client Records to a Third Party
Complete this form to select a secure method through which a third party will receive client records. This form can be submitted by the client, healthcare provider, legal professional, legal representative, personal representative, parent, or legal guardian.
Caution:
While using unsecured technology may be quicker and more convenient, it could compromise your privacy and is not recommended. However, it is common for clients to prefer unsecured communication for things like making/changing appointments or quick questions. It is also the right of the client to waive privacy when it comes to secure transmission of records, though I strongly discourage this choice. Please weigh the possible consequences of a privacy breach against the few extra seconds or minutes it might take to use secure technologies.
Request for Unsecured Communications
Use this form to request email, text, video, or phone communication over unsecured channels.
Request for Unsecured Records Transmission
This form should be completed only by clients or their legally designated personal or legal representatives. Use this form to request copies of your records over unsecured channels. Caution: Sending records over unsecured channels is not advisable for any reason.