Soul Affirming Counseling

Kerry Baharanyi, LICSW, PIP.

Intake Forms

02. Video Therapy Informed Consent

  • Type your full name
  • Date Format: MM slash DD slash YYYY

03. Confidentiality - HIPAA - Privacy - Social Media

  • THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
  • This document outlines clinic policies related to use of Social Media. Please read it to understand how our providers conduct ourselves on the Internet as a mental health professional and how you can expect us to respond to various interactions that may occur between us on the Internet. If you have any questions about anything within this document, you are encouraged to bring them up with your provider. As new technology develops and the Internet changes, there may be times when this policy needs to be updated. A copy of the updated policy will be posted at the clinic for your review.
  • Type your full name
  • Date Format: MM slash DD slash YYYY

04. Patient Authorization Disclosure for Protected Health Information

  • We only mail/secure email to physician offices and hospitals.


  • Disclosure To/From


  • This health information is disclosed for the following purpose (if Authorization requested by the patient put "At the request of the individual”
  • Date Format: MM slash DD slash YYYY
  • Type your full name
  • Date Format: MM slash DD slash YYYY

05. Individual wellness recovery plan

  • Goal One
  • Goal Two
  • Goal Three
  • Goal Four
  • Goal Five
  • What can I do to be calm and stay safe IN THE MOMENT?
  • What can my support person do to help?
  • Type your full name
  • Date Format: MM slash DD slash YYYY