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Unified Intake & Consent Package

I. Patient Demographics & Registration

Name:

First Name

Last Name

Date of Birth:

Gender:

Primary Phone:

Parent/Legal Guardian Name (If applicable):

Address:

City

State/Province

Zip/Postal

Address:

II. Comprehensive General Consent for Treatment

1. Scope of Services: I, the undersigned patient or legal guardian, hereby voluntarily consent to evaluation and care at
Carrousel Therapy Center Corporation (hereinafter “The Practice”). I understand that services provided may encompass a
broad, multi-disciplinary approach to physical, mental, and emotional health. I explicitly consent to participate in, and be
evaluated for, any of the following services as clinically indicated and collaboratively agreed upon:

     * Psychiatry and Medication Management
     * Mental Health Counseling (Individual, Group, and Family)
     * Psychosocial Rehabilitation
     * Targeted Case Management
     * Psychological Evaluations and Testing
     * Physical, Occupational, and Speech, Therapy
     * Any other relevant medical or therapeutic services introduced in the future to support my care plan.

2. Locations of Service: I consent to treatment being rendered at the following approved locations, subject to clinical
appropriateness (check all that apply):

The Practice’s Office

Patient’s Home

School Settings

HIPAA-compliant Telehealth

3. Waiver of Guarantee: I understand that my (or my child’s) plan of care is a collaborative effort between the Provider and
the family. All clinical recommendations must be followed to ensure the highest probability of improvement. However, because
every patient responds differently to treatment, The Practice cannot guarantee predetermined outcomes, and I acknowledge
that no such guarantees have been made.

4. Consent to Record: I consent to the recording of therapy sessions exclusively for clinical supervision, quality assurance,
and documentation purposes, fully protected under HIPAA and applicable state regulations.

III. Service Agreement & Financial Policy

This financial and service agreement sets forth the obligations required for maintaining an active clinical relationship
with The Practice. This policy is strictly enforced to align with industry ethics, insurance mandates, and operational
viability.

A. Cancellation and Tardiness Policy

     * Advance Notice: We require a minimum of 24 hours’ notice for cancellations. Please call ahead to cancel or
        reschedule.
     * Fees: We reserve the right to charge a fee of $50.00 for missed, unexcused absences and $25.00 for arriving 15 or
        more minutes late to a scheduled session.
     * Termination Risk: Routine tardiness or unexcused absences hinder clinical progress. Services may be terminated
        following three (3) unexcused absences or frequent irregular attendance.

B. Minors on Premises

For parents/legal guardians leaving the premises during a child’s appointment, you must return 10 minutes prior to
the end of the session to discuss treatment. If chronic tardiness in pick-up occurs, the parent will be required to remain
on-site during all subsequent sessions. The Practice is not a babysitting service; parents waive any liability regarding
the child’s safety after the session time has concluded. An active cell phone number must be provided.

C. Out-of-Pocket, Insurance, and Medicare/Medicaid Policy

     * Responsibility: The patient/guardian is responsible for notifying The Practice immediately of any changes to
        insurance. Insurance policies are contracts between the patient and the payer; if insurance denies a claim, the
        patient bears financial responsibility for the usual and customary charges.
     * Co-pays and Deductibles: State, federal, and private regulations strictly prohibit waiving or reducing co-payments
        and deductibles. The Practice is legally obligated to collect all applicable cost-sharing amounts required by your
        specific policy.
     * Hardships: Written notification detailing circumstances warranting a reduced fee is required. If a personal financial
        statement is approved, reduced fees may be granted for a period of six months.

D. Communications

By providing a mobile number, you consent to receive SMS text messages from The Practice related to appointment
reminders, scheduling, care coordination, and service notifications. Standard rates apply. You may opt out at any time.
We do not sell your data.

IV. Privacy, HIPAA, & Release of Information

Notice of Privacy Practices & Confidentiality: All information, including clinical assessments, diagnoses, and treatment
notes, is treated with strict confidentiality. No information will be released without written consent, except where federal or state
law mandates disclosure.

Federal Confidentiality Regulations (42 C.F.R. Part 2): Records pertaining to alcohol/drug abuse or mental status are
protected by Federal Law. These cannot be re-disclosed by receiving parties without specific written consent. Violators
may face fines under federal probation laws (Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and
Rehabilitation Act of 1970). 

Exceptions to Confidentiality: By law, information may be released without your consent under the following conditions:

     1. Abuse/Neglect: Suspected abuse or neglect of a minor, disabled, or elderly person must be reported to the
        Department of Children and Families.
     2. Duty to Warn: If a professional determines that a patient presents a direct threat to the life or safety of themselves or
         an identifiable third party.
     3. Court Order/Subpoena: If staff testimony or records are subpoenaed by a valid Court Order.
     4. Healthcare Operations: Disclosures to third-party payers for billing, or to coordinating health professionals to facilitate
         adequate care (in accordance with CFR Section 164.506).

HIPAA Release Authorization: I authorize The Practice to receive and discuss medical information (including previous health
records) with my other doctors, therapists, or medical professionals for the continuity of care. This consent remains valid for
one (1) year from the date of signature unless revoked in writing.

V. Telehealth Consent & Compliance Conditions

To engage in Telehealth services, the patient/caregiver must adhere to strict clinical and legal standards to protect
Private Identifying Information (PII) and Protected Health Information (PHI).

     * Minors: Children (age 17 or under) must be accompanied by a Caregiver/Parent during the session. If multiple
        children receive services, separate consents are required.
     * Environment: The patient must be in a private, enclosed location. Telehealth cannot be conducted in public places
        or with unauthorized individuals nearby.
     * Safety constraints: Telehealth sessions are strictly prohibited while the patient or caregiver is in a moving vehicle
        (driving, Uber, Taxi, etc.).
     * Technology: Connections must be made via the practice’s approved HIPAA-compliant platform. Public social
        video platforms (e.g., WhatsApp, Facebook Messenger) are non-compliant and prohibited.
     * Recording: The patient or family members are strictly prohibited from recording the session or standing off
        camera unannounced

Telehealth Consent Preference (Please select one):

I OPT-IN to receive Telehealth Services and agree to the conditions above.

I OPT-OUT of Telehealth Services and will only receive in-person care.

VI. Florida Patient’s Bill of Rights & Responsibilities

In accordance with Florida Statute 381.026, you are entitled to specific rights and obligated to certain responsibilities
while receiving medical care. You may request a full copy of the law; a summary follows:

Patient Rights

* To be treated with courtesy, respect, dignity, and privacy.
* To receive a prompt, reasonable response to questions and requests.
* To know the qualifications of the provider and what support services (including interpreters) are available.
* To be fully informed concerning diagnosis, planned treatment, alternatives, risks, and prognosis.
* To refuse any treatment, except as otherwise provided by law.
* To impartial access to treatment regardless of race, national origin, religion, handicap, or source of payment.
* To access emergency care if a condition will deteriorate without it.
* To receive an estimate of charges, an itemized bill, and explanation of charges upon request.
* To express grievances regarding any rights violations without retaliation.

Patient Responsibilities

* Providing accurate, complete information about
complaints, past illnesses, hospitalizations, medications,
and health history.
* Reporting unexpected changes in condition to the health
care provider.
* Informing the provider if a contemplated course of action
or expected behavior is not comprehended.
* Following the recommended treatment plan.
Keeping appointments, and notifying the facility when
unable to do so.
* Assuming full responsibility for actions if treatment is
refused or provider instructions are ignored.
* Ensuring that financial obligations for health care are
fulfilled as promptly as possible.
Following facility rules and regulations regarding patient
conduct.

I acknowledge receipt of the Consumer Handbook covering Rights, Privacy Practices, and Grievance Procedures, as well as instructions for Emergencies After Hours.

VIII. Master Acknowledgment & Signatures

By signing below, I certify that I have read, understood, and agree to abide by all the provisions outlined in this
Comprehensive Master Patient Intake & General Legal Consent Framework, including but not limited to:

* The General Consent for Treatment and Locations of Care

* The Service Agreement, Cancellation, and Financial Policies

* HIPAA Privacy Authorizations and 42 CFR Part 2 Releases

* Telehealth Consent and Safety Requirements

* The Florida Patient’s Bill of Rights and Responsibilities

I understand that my refusal to sign this consent, or later revocation thereof, may result in The Practice refusing to treat
me as permitted by Section 164.506 of the Code of Federal Regulations.

Printed Name of Patient (or Child)

Date of Birth:

Printed Name of Parent / Legal Guardian (If minor)

Relationship to Patient

Signature of Patient or Parent/Legal Guardian

Clear

Date

If you are human, leave this field blank.

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