Privacy Forms

The Consent for Services form outlines your agreement to participate in mental health services at Mandala Integrated Therapy. It provides information about the nature of therapy, your rights as a client, the risks and benefits of treatment, and how your information will be kept confidential. Signing this form indicates that you understand and agree to receive services and that you have had the opportunity to ask any questions you may have.

The Good Faith Estimate form provides an upfront summary of the expected costs for your mental health services at Mandala Integrated Therapy. In accordance with the No Surprises Act, this estimate is designed to help you understand and plan for the financial aspects of your care. It includes information about session fees, potential additional costs, and your right to receive a clear explanation of charges.

The Cancellation Policy form explains our guidelines regarding missed or rescheduled appointments. It outlines the required notice for cancellations, any applicable fees, and how consistent attendance supports the effectiveness of your treatment. Reviewing and signing this form ensures mutual understanding and helps us provide the best care to all clients.

The Patient Rights form outlines your rights as a client receiving services at Mandala Integrated Therapy. It includes information about your right to privacy, respectful treatment, participation in your care, and access to your records. This form ensures you are informed, empowered, and protected throughout your therapeutic journey.

The Release of Information form allows you to give written permission for Mandala Integrated Therapy to share your protected health information with specific individuals, providers, or organizations. This form ensures your confidentiality is respected while supporting coordinated care. You control what information is shared, with whom, and for how long.

At Mandala Integrated Therapy, we offer secure, confidential telehealth services using HIPAA-compliant video technology. Before starting virtual therapy, clients must complete a Telehealth Consent form, which explains the technology requirements, client rights, confidentiality protections, and emergency protocols. Clients are also required to disclose their physical location during each session to ensure safety and compliance with state licensing laws. This form ensures you understand and agree to participate in therapy remotely.

Mandala Integrated Therapy is committed to protecting your privacy and personal health information. Our Notice of Privacy Practices outlines how your medical and mental health information may be used, shared, and protected in accordance with HIPAA regulations. It also explains your rights regarding your records, including how to access them, request corrections, and set limits on disclosure. We encourage all clients to review this policy to understand how we keep your information safe and confidential.