Healthcare BASC Form

HEALTHCARE BASC FORM

The Behavioral Assessment and Service Consent (BASC) Form documents patient identification, clinical and administrative information, informed consent for behavioral assessment and treatment planning, authorization to release protected health information, and financial responsibility. Complete all applicable sections. Signing this form indicates understanding of the information below and consent to proceed in accordance with the terms set forth.

Patient Information

Date of Birth:    Gender: Male   Female   Other   Prefer not to say

Emergency Contact

Insurance & Billing

Referral / Requested Services

Requested Assessment / Service (select all that apply):
Diagnostic assessment   Treatment planning   Therapy / Counseling   Medication management   School / workplace evaluation   Other

Medical & Behavioral History

Safety screening (select if currently relevant):
Suicidal ideation or behavior   Self-harm behavior   Homicidal ideation or threats   Active hazardous substance use

Assessment Procedures, Risks, and Benefits

The behavioral assessment may include clinical interview, standardized rating scales, behavioral observation, collateral interviews, and review of available records. Expected duration and number of sessions will be determined by clinical need. Benefits include clarification of diagnosis, development of a treatment plan, and recommendations for supports. Risks include temporary emotional distress when discussing sensitive matters. If audio or video recording is proposed for clinical or training use, separate written consent is required.

Consent for audio/video recording: I consent to audio/video recording for clinical purposes only.

Voluntary participation and right to withdraw: Patient participation is voluntary. The patient or legal representative may withdraw consent for assessment or services at any time, subject to clinical and safety considerations and applicable legal obligations.

Use and Disclosure of Protected Health Information

Information obtained during assessment and treatment constitutes protected health information. This information will be used for assessment, treatment, billing, and quality improvement unless otherwise restricted. Certain disclosures are permitted or required by law, including mandated reporting of abuse, imminent risk of harm, and court-ordered disclosures.

Expiration of this authorization:    If no date is provided, authorization will expire one year from the date of signature unless a different period is specified by applicable law.

Revocation: The patient or legal representative may revoke this authorization in writing, except to the extent that action has already been taken in reliance on this authorization.

Acknowledgments

I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices describing how my health information may be used and disclosed and my rights regarding that information.

I acknowledge receipt of the Notice of Privacy Practices.

Financial Responsibility

The patient or responsible party is financially responsible for services rendered that are not covered by insurance or are outside plan benefits. Co-payments, deductibles, and non-covered charges are due at the time of service unless other arrangements are made.

Certification and Authorization

By signing below I certify that the information provided on this form is accurate to the best of my knowledge. I authorize the provision of behavioral assessment and related services as described above. I authorize release of relevant health information as specified for the purposes indicated. I understand the limits of confidentiality and the procedures for revocation of this authorization.

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