Intake and Consent Form

I give permission for mental /behavioral health therapy for myself or my child. I will be treated with respect and honesty throughout treatment. I am expected to benefit from treatment, but there are no guarantees. Maximum benefits will occur with regular attendance. I understand that I may temporarily feel worse while in treatment. I will let my therapist know if this begins to happen. I can discuss with my therapist if my goals in treatment are/ are not being met.

I will participate in the planning of my treatment services, and can refuse to participate in particular techniques as outlined by my therapist. I have the right to ask questions and seek clarification.

My therapist is engaging in a treatment relationship with the patient, and cannot participate in legal proceedings on behalf of a client or the client's family members. I understand and agree that if I want a mental health provider who participates in legal processes and decisions, that I will ask for a referral to an outside agency or provider that is competent to provide such services


I understand that the limits of confidentiality are: while under most circumstances communication between the client and the therapist is confidential, Pennsylvania State Law mandates the reporting of actual or suspected child or elder abuse to the appropriate agency. Also, if an individual intends to take harmful or dangerous action against another, it is the therapist’s ethical duty to warn the person or the family of the person who is likely to suffer the results of harmful behavior. Clients who may have suicidal desires are also reported and referred to the appropriate agency. Court orders may also mandate the release of confidential information. Every reasonable effort will be made to notify the client before such a compromise.

Although this office will process claims by billing insurance companies, I understand that payment for insurance deductibles and co-pays are my responsibility. We do not impose any charge for no-show/late cancellation appointments, nor do we use collection agencies for outstanding late payments. By signing below, I give permission for submission to my insurance company. I agree I may be responsible for costs outside of what my insurance covers.

I have the right to terminate the therapeutic relationship should I desire with or without explanation. At my request, my therapist may offer referrals to other therapists/agencies that may be helpful.

I understand my privacy and the Protected Health Information in the HIPAA information provided and available. I understand billing information (i.e. diagnosis) may be shared with others who need to arrange payment for my treatment by a third party payer (insurance companies). This office uses the professional billing services of Mental Health Billing Services, LLC. I understand that if I am concerned about shared information, I have the right to ask for and receive further explanation.

My mental health counselor may be receiving supervision. If this is the case, my therapist will discuss this with me and I will be notified of the name and contact information of the supervisor. The Practice mental health staff is composed of licensed psychologists (Ph.D., Psy.D.) and doctoral and master's level psychology interns, and licensed master's level therapists (LPC, LSW, LCSW).

In signing this document, I acknowledge and consent to John G. Kuna, Psy.D., Pennsylvania State Licensed Psychologist (License # PS016759) or his delegate, in supervising our therapy sessions.

I understand that Dr. Kuna will sign the claims submitted to the insurance company as the Supervising Psychologist. As such, I accept full responsibility for the charges incurred by my therapy sessions.