coming-soon - Caret Care

First Name(Required)

Last Name(Required)

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Phone

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone

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Practice Email

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

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Session Fee

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Client Full Name(Required)

Client Date of Birth(Required)

Billing Address

Street Address City State ZIP Code

Card Type(Required)

Name on Card(Required)

Date(Required)

URL

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Clinician Name and Credentials

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Practice Name

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Practice Phone

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Practice Email

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Practice Address

Street Address Address Line 2 City State ZIP Code

License Type

Licensed Clinical Social Worker (LCSW/LICSW)

Licensed Professional Counselor (LPC/LPCC)

Licensed Mental Health Counselor (LMHC)

Licensed Marriage and Family Therapist (LMFT)

Clinical Substance Abuse Counselor (CSAC)

Licensed Psychologist

Other

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License Number

Client Full Name

Date

After-Hours Phone / Voicemail Instructions

After-Hours Availability Window

988 Suicide and Crisis Lifeline: call or text 988

For immediate danger: call 911 or go to your nearest emergency room

Local Crisis Line (Optional)

Local Emergency Room

Session Contact Policy

Response Time Expectation

This policy complies with Wisconsin licensing requirements. [OTHER STATES MAY DIFFER]

By signing below, I confirm I have received, read, and understood this after-hours policy.

Client Signature: _____________________________ Date: ____________

Clinician Signature: _____________________________ Date: ____________

URL

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone Number

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Practice Email Address

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

Effective Date(Required)

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone Number

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Practice Email Address

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

Effective Date(Required)

URL

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone Number

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Practice Email Address

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

Effective Date(Required)

Phone

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone Number

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Practice Email Address

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

Effective Date(Required)

Facebook

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone Number

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Practice Email Address

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

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NPI Number

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Session Fee

Client Full Name(Required)

Client Insurance Plan

Date(Required)

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone Number

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Practice Email Address

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

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NPI Number

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Tax ID

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Session Fee

Client Full Name(Required)

Client Date of Birth(Required)

Client Address

optional

Street Address City State ZIP Code

Primary Diagnosis Code (ICD-10)(Required)

Secondary Diagnosis Code (ICD-10)

Additional Diagnosis Code (ICD-10)

CPT Code(Required)

Date of Service(Required)

Amount Charged

Amount Paid(Required)

Payment Method(Required)

Cash

Check

Credit Card

HSA-FSA

Superbill Date

Date superbill is generated

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone

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Practice Email

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

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Standard Session Fee

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Agreed Reduced Fee(Required)

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Fee Review Period(Required)

e.g. 90 days / 6 months / annually

Reason for Reduced Fee (Optional)

Brief financial hardship note

Client Full Name(Required)

Date(Required)

Phone

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone

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Practice Email

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

URL

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone

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Practice Email

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

Effective Date(Required)

Phone

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Practice Name

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Clinician Name and Credentials

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Practice Phone

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Practice Email

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

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Client First Name(Required)

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Client Last Name(Required)

Appointment Date(Required)

Appointment Time(Required)

Session Format(Required)

In-Office

Telehealth

Hybrid (first session in-office)

Office Address Override

Leave blank to use practice address.

Parking or Building Access Notes

Leave blank to omit this section from the letter.

Telehealth Platform

e.g. SimplePractice, Doxy.me. Leave blank to omit.

Telehealth Link

Full URL. Leave blank to omit.

Telehealth Tech Notes

e.g. "Test your link 5 minutes before your session." Leave blank to omit.

Paperwork Delivery Method(Required)

Sent via client portal

Sent via email

Will be completed at first session

Paperwork Deadline

e.g. "Please complete at least 24 hours before your session." Leave blank to omit.

Portal or Paperwork Link

Full URL. Leave blank to omit.

Contact Person for Pre-Session Questions

Leave blank to default to clinician name in PDF.

Contact Phone for Pre-Session Questions

Leave blank to default to practice phone in PDF.

Contact Email for Pre-Session Questions

Leave blank to default to practice email in PDF.

Personal Welcome Note

Free-form. Leave blank to omit this section from the letter entirely.

Name

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone

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Practice Email

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

Effective Date(Required)

Phone

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Client Full Name

Shown on the client copy of this document.

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone

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Practice Email

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

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Cancellation Notice Required

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Late Cancellation Fee

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No-Show Fee

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Late Arrival Policy

Instagram

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone

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Practice Email

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

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Refund Window(Required)

e.g. 30 days

Refund Method(Required)

Original payment method

Practice credit

Check

No refunds issued

Billing Dispute Window(Required)

e.g. 30 days from date of service

Effective Date(Required)

Name

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Practice Name

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Clinician Name and Credentials

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Practice Phone

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Practice Email

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

Intake Delivery Method(Required)

Sent via EHR client portal before first session

Emailed directly to client

Completed in session at first appointment

Consultation Call Offered(Required)

Yes. Free consultation before intake

Yes. Paid consultation before intake

No. Clients go directly to intake scheduling

Documents Included in Intake Sequence(Required)

Intake Sequence Order(Required)

List your documents in the order you send them. One document per line.

Timing: When Documents Are Sent(Required)

48+ hours before first session

24–48 hours before first session

Same day as scheduling confirmation

Day of first session

Signature/Completion Confirmation Method(Required)

EHR e-signature

Signed PDF returned by client

Handwritten signature collected in session

Not yet established

Pre-Session Review Step(Required)

Yes. I review all signed documents before every first session

No. I do not have a pre-session review step

Intake Notes

Instagram

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Practice Name

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License Type and Number

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Clinician Name and Credentials

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone

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Practice Email

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

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Cancellation Notice Required

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Late Cancellation Fee

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No-Show Fee

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Late Arrival Policy

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Client Full Name(Required)

Date(Required)

Comments

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Client Full Name

Shown on the client copy of this document.

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Practice Name

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Clinician Name and Credentials

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Practice Phone

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Practice Email

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

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After-Hours Voicemail Instructions

Session Fee(Required)

Session Length(Required)

Cancellation Notice Required(Required)

Late Cancellation Fee(Required)

Record Retention Period(Required)

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Practice Name

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone

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NPI Number

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EIN

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Clinician Name and Credentials

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Practice Logo URL

Client Full Name

Client Date of Birth

Client Address

Street Address City State ZIP Code

Date of Estimate

Estimated Start Date

CPT Code 1

Service Description 1

Estimated Sessions 1

Fee Per Session 1

CPT Code 2

Service Description 2

Estimated Sessions 2

Fee Per Session 2

ICD-10 Diagnosis Code(s)

Grand Total

Client Signature

Date Signed

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Practice Name

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Clinician Name and Credentials

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Practice Phone

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Practice Email

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

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Telehealth Platform

EHR System

Scheduling Tool

Clinical Email Provider

Payment Processor

Practice Phone System

Telehealth BAA Status

BAA signed

BAA pending

Not applicable

EHR BAA Status

BAA signed

BAA pending

Not applicable

Scheduling BAA Status

BAA signed

BAA pending

Not applicable

Email BAA Status

BAA signed

BAA pending

Not applicable

Payment BAA Status

BAA signed

BAA pending

Not applicable

Phone BAA Status

BAA signed

BAA pending

Not applicable

Client Contact Preference

Phone call

Text message

Secure portal message

Client Name (Printed)

Date

X/Twitter

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Client Full Name

Shown on the client copy of this document.

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Practice Name

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Clinician Name and Credentials

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Practice Phone

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Practice Email

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone

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Practice Email

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

Date Completed(Required)

Review Cycle(Required)

Annual

Semi-annual

After any security incident

Primary Device Type(s) Used for Clinical Work(Required)

Personal laptop

Dedicated work laptop

Desktop

Tablet

Smartphone

Shared device

Devices require password or biometric authentication(Required)

Confirmed

Devices are set to auto-lock after inactivity(Required)

Confirmed

Not yet configured

Full-disk encryption is enabled on all clinical devices(Required)

Confirmed

Not applicable to my device type

Not yet configured

Devices are never left unattended with client records visible(Required)

Confirmed

No unencrypted client records are stored locally on any device(Required)

Confirmed

I store some records locally

Password management method(Required)

I use a dedicated password manager

I use unique passwords without a manager

Other

Multi-factor authentication (MFA) is enabled on EHR login(Required)

Yes

Not available on this platform

MFA is enabled on email used for client communication(Required)

Yes

Not available on this platform

Single choice: Confirmed

Passwords are changed following any suspected unauthorized access(Required)

Confirmed

Primary ePHI storage method(Required)

Cloud-based EHR with BAA

Local encrypted storage only

Paper records in a secured location

Combination

No client data is stored in consumer-grade platforms without a BAA(Required)

Examples of consumer-grade platforms that require a BAA before use with client data: standard Google Drive, Dropbox, iCloud, standard Gmail.

Confirmed

Client records are not stored in texts, standard email, or unsecured notes apps(Required)

Confirmed

EHR Platform Name(Required)

EHR BAA Status(Required)

BAA in place

BAA requested, not yet signed

No BAA confirmed

Email Platform Name(Required)

Email BAA Status(Required)

BAA in place

BAA requested, not yet signed

No BAA

Email not used for any PHI

Telehealth Platform Name

Telehealth BAA Status(Required)

BAA in place

BAA requested, not yet signed

No BAA

Telehealth not offered

Additional Vendor Name (if any)

Any other platform that stores, transmits, or accesses client info. Enter N/A if none.

Additional Vendor BAA Status

BAA in place

No additional vendors

Remote access posture(Required)

Only from secured personal devices

Occasionally from other devices with precautions

From public or shared networks

VPN use when accessing records off-site(Required)

Yes, I use a VPN

Not applicable. I never access records remotely

Client records are never accessed through public Wi-Fi without a VPN(Required)

Confirmed

Not applicable

Breach notification policy is documented(Required)

Yes, documented

In progress

Not yet addressed

I know the 60-day breach notification deadline under the HIPAA Breach Notification Rule(Required)

Confirmed

HHS Office for Civil Rights contact information is on file(Required)

Confirmed

Review Date(Required)

Changes Since Last Review(Required)

Describe any changes to devices, platforms, or security practices since last review. If first completion, write Initial completion.

Attestation(Required)

confirm that I have reviewed my technical safeguards and that the information in this document reflects my current security posture to the best of my knowledge.

Clinician Signature (Printed Name)(Required)

Type your full name as your attestation signature.

Client Full Name

Shown on the client copy of this document.

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Practice Name

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Clinician Name and Credentials

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Practice Phone

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Practice Email

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

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Telehealth Platform

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Practice Name

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Clinician Name and Credentials

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone

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Practice Email

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State of Practice

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Practice Logo URL

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Primary Brand Color

This field is hidden when viewing the form

Secondary Brand Color

Record Format(Required)

Electronic records (EHR or digital storage)

Paper records

Both electronic and paper

Retention Period: Adult Client Records(Required)

5 years from last date of service

7 years from last date of service

10 years from last date of service

Other

Retention Period: Adult Client Records

Minor Client Records Acknowledgment(Required)

I understand that records for minor clients must be retained until the client reaches age 19, plus my standard retention period, whichever is longer. Your State laws may set a different age threshold. Confirm with your state licensing board.

Destruction Method: Paper Records(Required)

Cross-cut shredding

Contracted document destruction service

Destruction Method: Electronic Records(Required)

Certified deletion / secure wipe via EHR platform

Manual secure deletion and confirmation log

Storage Security Confirmation(Required)

Active client records are stored in a HIPAA-compliant system

Paper records (if applicable) are stored in a locked, secured location

Electronic records (if applicable) are password-protected and access-controlled

I do not store client records on personal devices without encryption

Policy Acknowledgment

I have reviewed this policy, it reflects my current practice setup, and I understand that state-specific requirements may differ from Wisconsin defaults. I will confirm any state-specific obligations with my licensing board before seeing clients

Effective Date

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address City State ZIP Code

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Practice Phone Number

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Practice Email Address

Effective Date(Required)

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Practice Name

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Clinician Name and Credentials

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License Type and Number

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Practice Address

Street Address Address Line 2 City State ZIP Code

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Practice Phone

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Practice Email

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

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After-Hours Voicemail Instructions

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Clinician After-Hours Availability

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Local Crisis Line Name

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Local Crisis Line Phone

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Local Emergency Room Name

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Local Emergency Room Address

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Practice State

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Practice Name

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Clinician Name and Credentials

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Practice Address

Street Address City State ZIP Code

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Practice Phone

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Practice Email

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Practice Logo URL

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Primary Brand Color

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Secondary Brand Color

Client Full Name

Date

Client Address

Street Address City State ZIP Code

Client Phone

Direction of Release

Release TO

Release FROM

Recipient or Source Name

Recipient or Source Organization

Recipient or Source Address

Street Address Address Line 2 City State ZIP Code

Recipient or Source Phone

Recipient or Source Fax

Information to Release

Psychotherapy notes

Treatment summaries and progress notes

Diagnostic evaluations and assessments

Medication records

Discharge summaries

Dates of service only

Other

Other (please specify)

Date Range Start

Date Range End

Purpose of Disclosure

Expiration Date

Expiration Event

Required if Expiration Date is not selected. e.g. "Upon completion of treatment"

Client Signature

"Print and sign, or complete via your practice's designated signature process."

Printed Name

Authorized Representative Signature

Only completed if representative is signing

Authorized Representative Printed Name

Only completed if representative is signing

Relationship to Client

Date Signed

IN DEVELOPMENT

Caret Care Waitlist

No spam. Just a heads up when the doors open.

Build by clinicians for clinicians.

BUSINESS FORMATION

Entity type, registration, EIN, and banking

Walked through in the right sequence, with nothing assumed. You'll know what to do and why it matters.

Compliance foundations

HIPAA, No Surprises Act, insurance, clinical documentation

Every compliance requirement a solo practice needs, built before your first client session.

Guided execution

Not a course. Not a checklist.

A step-by-step build system that saves your progress and meets you where you are.

IN DEVELOPMENT

Caret Care Waitlist

No spam. Just a heads up when the doors open.

Build by clinicians for clinicians.

BUSINESS FORMATION

Entity type, registration, EIN, and banking

Walked through in the right sequence, with nothing assumed. You'll know what to do and why it matters.

Compliance foundations

HIPAA, No Surprises Act, insurance, clinical documentation

Every compliance requirement a solo practice needs, built before your first client session.

Guided execution

Not a course. Not a checklist.

A step-by-step build system that saves your progress and meets you where you are.

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

Let's Generate Your Document

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