Releases

Email

Your email address

Patient Name

First

Last

Name (persons under 16 years of age)

First

Last

Confidentiality is not granted by law for people under the age of 16 unless a custodial parent or legal guardian grants limited confidentiality. In cases where there is an emergency or an urgent need to know I will be notified immediately. If limited confidentiality is granted, the clinician will not meet with the custodial parent or the legal guardian without the minor present or if there are extraordinary circumstances where the minor may not be present. The rules for confidentiality when meeting with minors is located here

Consent to Limited Confidentiality for a minor child.

Cornwall Counseling is in compliance with the HIPPA Privacy Act by protecting email, text, and patient files using the standards set forth in 45 CFR § 164.520 - Notice of privacy practices for protected health information.

* HIPAA policy

I request to release confidential information to the following individuals or entities:

* View ROI policy

Please provide the name(s), address(es), nature of the relationship to the patient(s), telephone number(s) and email address(es) of the individual(s) or entities with whom you wish to freely share confidential information.

Please provide information related to Release of Information Requests

Cornwall Counseling completes forms, letters, and other written materials. These forms are not billable through your insurance. If you will be requesting Leave of Absence (LOA), Family Medical Leave Act (FMLA), Disability, Emotional Support Animal (ESA), Court Reports or any written documents, please visit the link below.

Request for Specialized Documents

For many mental health conditions, clinicians frequently recommend the use of psychotropic medications—medications that can influence a person’s behavioral health condition—as a way of making talk-therapy more useful to the patient. A session with one of our therapists can be a starting point for discussing the potential benefits or concerns related to taking medication to assist behavioral health concerns. While medication can provide symptom relief, it does not necessarily address underlying maladaptive behaviors, and is therefore considered by many clinicians and adjunct to treatment, rather than the primary mode of treatment itself.

Medication Evaluation / Management

Patients in our practice may opt to be contacted via email and/or text messaging to remind them of an appointment, to obtain feedback on your experience with our healthcare team, or to provide general health reminders/information. Please choose from the following options:

* I understand that my request to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing.

Patients in our practice may opt to be contacted via email and/or text messaging after 90 days of their last appointment to check on their well-being and to obtain feedback on their experience with our healthcare team.

* I understand that my request to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing.

Cancellation Policy Acknowledgement: Please understand that appointment times are limited. If you must cancel your appointment, we require 24-hour notice. Missed appointments, or appointments cancelled without 24-hour notice will incur a $50.00 cancellation fee. THERE ARE NO EXCEPTIONS. You can cancel online through the scheduling portal, by calling or texting (859) 321-4956, or by emailing mcornwall@cornwallcounseling.com

* Scheduling Portal

Comment or Message

Please provide feedback using this space, send us an email, or a text at 888.852.7670, or by completing the Patient Satisfaction Survey