James Fitzgerald Therapy PLLC

Intake Documents & Forms

Therapy Portal (Therapy Notes, LLC)

The documents listed on this page are located in the client account portal, to be shared with you by your therapist.

Consultation:

  • Clinician’s Professional Public Disclosure Statement for Licensed Clinical Mental Health Counselors
  • Vermont State Office of Professional Regulation Rules for Licensed Clinical Mental Health Counselors
  • Confidentiality Statement (Client Rights & Limits of Privacy)
  • Notice of Privacy Practice

Intake:

  • Client Information Form
  • Client Insurance Form
  • Client History Form
  • Payment Authorization Form
  • Emergency Contacts Form
  • Medications & Supplements Form

Informed Consent:

  • Consent for Services
  • Consent for Clinician to use AI Note Writing Software
  • Therapy Agreement: Policies & Procedures
  • Consent for Telehealth
  • Consent for Electronic Communication
  • No Surprises Act
  • Advance Beneficiary Notice

Other Documents:

  • Terms & Conditions of Use (Library of Documents)
  • Ethical Compliance Practices of James Fitzgerald Therapy, PLLC
  • Technology used by the Clinician
  • Authorization to use or disclose Protected Health Information (Signed Release)
  • Client Manual & Handbook
  • Treatment Planning Handbook