Healthcare Behavioral Services Form

Healthcare Behavioral Services Form

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Emergency & Referral

Insurance & Billing

I authorize the practice to bill my insurance: Yes No

Medical & Behavioral Health History

Current concerns / presenting problems (check all that apply):

Anxiety Depression Anger/Irritability Sleep Disturbance Substance Use Trauma/PTSD

Risk Assessment & Safety

Within the past two weeks have you had thoughts of harming yourself? Yes No

Within the past two weeks have you had thoughts of harming others? Yes No

Consent for Behavioral Services

I authorize and consent to behavioral health evaluation and treatment provided by licensed clinicians and supervised trainees at this practice. Services may include assessment, psychotherapy, counseling, behavior interventions, group therapy, and case management as clinically indicated.

I understand that behavioral health treatment has potential benefits and risks. Benefits may include improved mood, functioning, and symptom reduction. Risks may include uncomfortable emotions, temporary increase in symptoms, and changes in relationships. No guarantee of specific outcomes is made.

I understand I have the right to withdraw consent at any time, except to the extent that action has already been taken in reliance upon this consent. Withdrawal of consent must be submitted in writing.

Confidentiality & Limits

Information disclosed in treatment is confidential and will not be released without my written authorization, except as required or permitted by law. Exceptions include: (1) imminent risk of harm to self or others; (2) suspected abuse or neglect of a child, elder, or dependent adult; (3) court order or subpoena; (4) when necessary to coordinate care with other health providers as authorized.

I acknowledge receipt of the practice’s privacy practices and understand how my protected health information may be used for treatment, payment, and healthcare operations.

Telehealth & Electronic Communication

I consent to receive services by telehealth where clinically appropriate. I understand telehealth has benefits and limitations, including potential technological failures and privacy risks. I agree to use a private location for sessions and to follow clinician instructions to maximize privacy.

I consent to communication via telephone, secure messaging, and email for scheduling and limited clinical matters. I understand that email/text communications are not fully secure and urgent matters should be communicated by phone.

Authorization for Release of Information (Optional)

I authorize the release of my behavioral health information to:

Expiration date of this authorization:

I understand I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on it.

Financial & Administrative Acknowledgments

I accept financial responsibility for services rendered if not covered by insurance or if my insurer denies payment. I agree to pay co-payments, deductibles, and non-covered charges at the time of service. I acknowledge the practice’s cancellation and no-show policies and that missed sessions may result in fees.

In emergencies outside of scheduled sessions, I understand the clinician may need to contact emergency services or my emergency contact when my safety is at risk.

Patient Acknowledgment

By signing below I certify that the information on this form is true and complete to the best of my knowledge. I have read and received a copy of the practice’s privacy notice and understand the terms of treatment, billing, and confidentiality described above. I consent to behavioral health services as described in this form.

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