New Client Paperwork

Please click on the appropriate link below to download the paperwork for your first appointment.  Please bring the paperwork completed to your first appointment or arrive at your appointment 20 minutes early to complete the paperwork in the office.

• Individual therapy
• Adult Intensive Outpatient Program
• Adolescent Intensive Outpatient Program
• Family therapy
• Couples counseling

Notice of Privacy Practices

Information about your visits to Sage Recovery & Wellness Center are considered protected health information (PHI). Sage Recovery & Wellness Center is required by law to maintain the privacy of your information and to provide you with this notice that details our privacy practices. Sage Recovery & Wellness Center keeps your health information in confidential records that are maintained and protected, as required by law. With the exception of disclosures permitted in this notice, no one except Sage Recovery & Wellness Center staff will have access to your information.

Information you provide to Sage Recovery & Wellness Center will be used to provide services to you and to ensure quality of care. Except as described in this notice or when required/permitted by state/federal law, Sage Recovery & Wellness Center will not disclose your information unless you provide a written authorization for us to disclose your information. If you authorize Sage Recovery & Wellness Center to disclose your information, you make revoke this authorization in writing at any time, except to the extent that the information has already been disclosed.

Uses and Disclosures:

• Sage Recovery & Wellness Center may use or disclose your information for the following purposes:
  • To notify you when an appointment is cancelled or rescheduled
  • To disclose relevant information in cases of a serious, imminent threat to health or safety
    • In accordance with Texas law, if any individual arrives at Sage Recovery & Wellness Center under the influence of any substance that causes impairment and has driven themselves to the center, the individual will be assisted in finding a safe, alternative ride home. If the individual should choose to drive themselves home after being informed of this regulation, staff members will be required to inform the legal authorities of this.
  • For public health purposes, such as mandated reporting of suspected abuse, neglect, or exploitation of a child, an elderly person, or a person with a disability or mandated reporting of a provider of counseling services behaving in a sexually inappropriate manner.
  • As ordered by a court – Sage Recovery & Wellness Center will attempt to contact you before disclosing information from your record in response to a subpoena or court order. In certain situation where you bring legal action against the organization, Sage Recovery & Wellness Center may be required to release your information to officers of a court.
  • For limited national security purposes, such as to military command authorities if you are a member of the armed forces or for national security and intelligence activities
  • For mental health oversight activities, such as a State Board investigation or a record-keeping audit
• Sage Recovery & Wellness Center Duties:
  • Sage Recovery & Wellness Center is required to abide by the terms of the privacy notice that is currently in effect. This notice of privacy practices is effective 1/1/14.
  • Sage Recovery & Wellness Center may change the terms of our privacy practices. Any future changes to the terms will apply to all previous and future health information that Sage Recovery & Wellness Center
  • Approximately 10 years after you contact Sage Recovery & Wellness Center, the center will destroy your record in a way that protects your privacy.
  • You have the right to request restrictions on certain uses and disclosure of your information. Sage Recovery & Wellness Center is not required to agree to a requested restriction.
• Your individual rights:
  • You have the right to receive confidential communications.
  • You have the right to inspect and copy your record, however, you will not receive the original copy. Under limited circumstances, your request may be denied. You may request review of this denial and the Sage Recovery & Wellness Center will discuss with you the details of the review process. If you believe the information we have about you is incorrect or incomplete, you may request an amendment to the record. Sage Recovery & Wellness Center is not required to accept the amendment.
  • You may request a list of the disclosures of your information.
  • If you believe your privacy rights have been violated, you may file a written complaint with the Sage Recovery & Wellness Center CEO, Joint Commission, or HIPAA. You will not be retaliated against if you make a complaint.
  • You have a right to a paper copy of this notice (or any future privacy notices). Please let the office manager know if you would like a copy of this notice.

If you have any questions about this notice, have a complaint, or wish to exercise your individual rights, please contact the Sage Recovery & Wellness Center at (512) 306-1394.