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New Client Intake Form

Complete the information below to begin your journey with Spectrum Counseling. All information is kept strictly confidential.

1

Client Information

By submitting this form, you agree to receive SMS from Spectrum Counseling, LLC. Carrier and data rates may apply. Reply STOP to end or HELP for info.

2

Partner / Minor Information

Optional — complete if seeking couples therapy or if client is a minor.

3

Clinical Background

4

Areas of Concern

Select all that apply to you.

5

Payment & Insurance

Dr. Haddox does not accept insurance directly. Please select your preference below.

Financial Responsibility

The client/responsible party is responsible for payment of professional services at the time they are rendered.

By signing below, I certify that I, the client/responsible party, acknowledge that Dr. Haddox does not accept any health insurance and will not submit claims for reimbursement to any insurance company on my behalf.

6

HIPAA Notice of Privacy Practices

In accordance with the Health Insurance Portability and Accountability Act (HIPAA) and its amendments, including the HITECH Act and the 2013 Omnibus Rule, this notice describes how your protected health information (PHI) may be used and disclosed, and how you can access this information.

Uses and Disclosures of PHI

Your PHI may be used or disclosed for the following purposes:

  • Treatment: To provide, coordinate, or manage your mental health care and related services.
  • Payment: To obtain payment for services, including billing and collections activities.
  • Health Care Operations: For quality assessment, staff training, and other administrative activities.
  • As Required by Law: When required by federal, state, or local law, including mandatory reporting of abuse, neglect, or threats of harm.

Your Rights Regarding PHI

  • Right to Access: You may request access to your PHI and obtain a copy of your records.
  • Right to Amend: You may request amendments to your PHI if you believe it is inaccurate or incomplete.
  • Right to Restrict: You may request restrictions on certain uses and disclosures of your PHI.
  • Right to Confidential Communications: You may request to receive communications by alternative means or at alternative locations.
  • Right to an Accounting: You may request an accounting of disclosures of your PHI made by this practice.
  • Right to a Copy of This Notice: You may request a paper copy of this notice at any time.
  • Right to File a Complaint: You may file a complaint with Spectrum Counseling, LLC or the U.S. Department of Health and Human Services if you believe your privacy rights have been violated.

Psychotherapy Notes

Under HIPAA, psychotherapy notes receive additional protection. These notes are maintained separately from your medical record and will not be disclosed without your written authorization, except in limited circumstances as permitted by law.

Substance Use Disorder (SUD) Records

SUD treatment records are protected by federal law (42 CFR Part 2) and Arizona law (A.R.S. § 32-2085) and carry stricter confidentiality protections than standard medical records. These records may not be disclosed without your written consent, a court order, or as otherwise permitted by law.

  • Your Rights: You have the right to an accounting of disclosures and to request restrictions on certain disclosures of your SUD records.
  • Counseling Notes: SUD counseling session notes are maintained separately and require specific written consent before disclosure.
  • Legal Proceedings: SUD records may not be used in any civil, criminal, administrative, or legislative proceeding against you without your written consent or a court order.
  • Consent: A single written consent may authorize use and disclosure of your SUD records for treatment, payment, and health care operations for future disclosures unless revoked in writing.
  • Breach Notification: You will be notified of any breach of your SUD records per HIPAA requirements.
  • Re-disclosure: Once disclosed, SUD records may no longer be protected and could be re-disclosed by the recipient.

Breach Notification

In the event of a breach of unsecured PHI, Spectrum Counseling, LLC will notify you as required by the HITECH Act and the Breach Notification Rule.

This notice is effective as of the date signed below. Spectrum Counseling, LLC reserves the right to change the terms of this notice at any time. Changes will apply to all PHI maintained by the practice.

By signing below, I acknowledge that I have received and reviewed the HIPAA Notice of Privacy Practices for Spectrum Counseling, LLC.

7

Acknowledgment

By submitting this form, I acknowledge that:

I understand Dr. Haddox does not accept any health insurance and will not submit claims for reimbursement.

I am responsible for payment of professional services at the time they are rendered.

I understand that appointments cancelled without 24-hour notice will be billed at a rate of $75. Third and subsequent late cancellations, as well as appointments missed without any notice, will be billed the full session fee. These fees may be charged to the credit card on file.

I voluntarily agree to receive mental health assessment, care, treatment, or services.

I understand I may stop care at any time.

Your information is transmitted securely and kept confidential.

Form Submitted Successfully

Thank you for submitting your new client information. Dr. Haddox will review your form and contact you to schedule your first session.

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