Anger Management Registration & Consent

Your Name (First, MI, Last)	Today’s Date:
Street Address	City	State	Zip
County	Preferred Phone (With Area Code) OK To Leave Message?	Preferred Email OK To Send Message?
Age	DOB (MM/DD/YYYY)	Gender
Emergency Contact Name, Phone Number, & Relationship To You
Do you need accommodations regarding written, audio, or visual materials? If yes, please provide details:
Are you currently employed? If yes, Employer Name and location:	Who referred you to this program?
Confidentiality Confidentiality is the cornerstone of counseling and protecting your privacy is a top priority. Your involvement in services and the details of your treatment cannot be disclosed to anyone without your written consent, unless mandated by law. You maintain the right to revoke that consent at any time. When disclosure is required or requested, our approach is to release the minimal amount of information needed to meet that particular request. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). Limits to confidentiality include the following: If the client poses risk of imminent danger to self or another person. If the client is at high risk for suicide. In the event of actual or suspected physical or sexual abuse of a child, an elderly person, or a dependent adult. If the counselor receives a valid court order for a client’s medical records.
Electronic Communication Journey Well, LLC allows the use of email and text with clients solely for the purpose of arranging appointments. Information regarding diagnosis or treatment will NOT be communicated via email/text. Privacy concerns involved in electronic transmissions include: potential to be received by unintended recipients, to be forwarded without the sender’s or intended recipient’s permission or knowledge, or to be misaddressed; back-up copies may exist after the sender or the recipient has deleted them; and it is easier to falsify than signed paper documents. Journey Well, LLC takes all reasonable means to protect clients’ confidentiality but cannot guarantee the security and confidentiality of email or text communication and is not liable for improper disclosure of confidential information not caused by negligence or misconduct. The client is responsible for protection of their own password or other means of access to email/text sent or received. Journey Well, LLC is not liable for breaches of confidentiality caused by the client. If you do not receive a response to an email/text within one business day, please follow up with a phone call. Journey Well, LLC will share protected health information with outside entities via email only with clients’ written authorization.
Payment Agreement $180.00 Received on ____________

*Please note that Journey Well, LLC is a tobacco-free, non-smoking facility.*

Participant’s Signature: _____________________________________	Date: __________

Facilitator’s Signature: ______________________________________	Date: __________