Client Counseling Forms
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.
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.
Complete this form during the intake process before you begin therapy. This form is not publicly available. I will grant you access once I receive your initial contact form.
Informed Consent Agreement (not publicly available)
Complete this form during the intake process before you begin therapy. I will send you the link once I receive your initial contact form.
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.
Please complete this form before every session. This form is not publicly available. I will grant you access once I receive your initial contact form.
Complete this form to verify that you are located in the state of Florida. At this time, I am licensed to provide therapy in the state of Florida only. This form is not publicly available. I will grant you access once I receive your initial contact form.
Please use this form to indicate where you would like to receive your weekly quote cues.
Please complete this form when you receive a new treatment plan(s) or when we discuss changes to your treatment plan(s).
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.)
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.
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.
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.
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.
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.
This form should be completed by collaterals only after the client has completed the form titled Authorization for Disclosure and Release of Confidential Information.
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.
Use this form when you need to reschedule an appointment. Please be mindful of the cancellation policy, which you can review on my therapy services and fees page.
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.
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.
Use this form to request email, text, video, or phone communication over unsecured channels.
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.