Healthcare Behavioral Health Application

Healthcare Behavioral Health Application

Patient Information

Date of Birth:    Gender: Male Female Non-binary Other

Emergency Contact

Insurance Information

Subscriber Date of Birth:

Medical & Mental Health History

Please indicate any current or past diagnoses or conditions (select all that apply):

Depression
Anxiety Disorder
Bipolar Disorder
Post-Traumatic Stress Disorder (PTSD)
Attention-Deficit / Hyperactivity Disorder (ADHD)
Psychotic Disorder / Schizophrenia
Substance Use Disorder
None of the above / Not diagnosed

Risk & Safety Screening

History of suicide attempt or current suicidal ideation: Yes No

Current homicidal ideation or threat to others: Yes No

Substance Use

Current alcohol or drug use: Yes No

Consent for Treatment

I authorize clinicians and staff of this practice to provide assessment, psychotherapy, and other behavioral health services as clinically indicated. I understand that treatment is voluntary, that I may refuse or withdraw consent at any time, and that the clinician will discuss treatment goals, anticipated benefits, potential risks, and alternative interventions. I understand that no guarantees have been made regarding outcome.

I further authorize the use of telehealth modalities when appropriate and consent to electronic communications for scheduling and clinical purposes, understanding the limitations and risks of electronic communications including privacy risks.

I consent to receive behavioral health services and assessment from the provider named on this application.

Confidentiality & Limits

All information provided to clinicians is confidential and will not be released without written authorization, except as required or permitted by law. Exceptions include: (1) reasonable suspicion of child, elder, or dependent adult abuse or neglect; (2) if there is a serious and imminent threat of violence to another person or to self; (3) if required by court order; and (4) where otherwise required by law (for example certain communicable disease reporting). Clinicians will make reasonable efforts to discuss limits of confidentiality with the patient prior to disclosure when feasible.

Release of Information Authorization

I authorize the release of my protected health information as described below. I understand that this authorization is voluntary and may be revoked in writing except to the extent action has already been taken in reliance on it.

Specific information to be released: Progress notes / psychotherapy notes Medical records Discharge summary Substance use treatment history

Financial Responsibility & Billing

I understand that I am responsible for payment of services at the time rendered unless other payment arrangements have been agreed in writing. I authorize the release of any information required to process insurance claims and, where applicable, assign benefits to the provider. I understand that I remain financially responsible for any charges not covered by insurance, including co-payments, deductibles, and services denied by my insurer.

I authorize payment of insurance benefits directly to the provider and assign such benefits to my provider where permitted.

Appointment & Cancellation Policy

Appointments missed without 24 hours notice may be subject to a cancellation or no-show fee. Fees that are not covered by insurance are the patient's responsibility. Repeated missed appointments may result in discharge from care.

HIPAA Acknowledgment

I acknowledge that I have been offered or provided a notice of privacy practices describing how my health information may be used and disclosed, and my rights regarding my protected health information. I understand that I may request restrictions or confidential communications, and that requests will be considered by the provider.

I acknowledge receipt of the privacy practices notice.

Attestation

I certify that the information I have provided on this application is true and accurate to the best of my knowledge. I understand that providing false information may affect my eligibility for services and may be grounds for termination of treatment.

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