Healthcare BIP Intake Packet

HEALTHCARE BIP INTAKE PACKET

Client Information

Date of Birth:

Male Female Non-binary Other:

Emergency & Contacts

Referral & Provider Information

Date of Intake:

Insurance & Billing

Medical & Psychiatric History

History of suicidal ideation or attempts: Yes No If yes, most recent date:

Presenting Concerns and Functional Assessment

Behavioral Intervention Plan (BIP) Details

Use of restrictive procedures (restraint, seclusion, aversive techniques): None planned Specified below

Consent for Treatment and BIP Implementation

I, the undersigned, authorize the implementation of the Behavioral Intervention Plan described above. I understand that:

1. Interventions will be implemented in accordance with the least restrictive principles and applicable professional standards.
2. Staff carrying out interventions will document incidents, monitor outcomes, and report any use of restrictive procedures to the appropriate clinical supervisor.
3. I have received an explanation of foreseeable risks and benefits of the planned interventions, alternatives to the plan, and expected outcomes.
4. I may withdraw consent at any time by submitting written notice, except when withdrawal would endanger the client or others under applicable law.

Consent to BIP Implementation: I CONSENT I DO NOT CONSENT

HIPAA Authorization & Release of Information

I authorize the use and disclosure of my protected health information (PHI) to the persons and organizations identified below for purposes of treatment, care coordination, and payment related to the BIP and behavioral health services. This authorization includes summary information about behavioral incidents, clinical assessments, progress notes, and incident reports as necessary for coordination of care.

This authorization expires on:

I understand that I may revoke this authorization at any time by providing written notice to the provider, except to the extent that action has already been taken in reliance on this authorization. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy rules.

Client Rights & Acknowledgment

By signing below I acknowledge that I have been advised of my rights, including the right to receive information about treatment options, to ask questions about the BIP and its implementation, and to file a complaint or grievance regarding care. I attest that the information provided in this intake packet is accurate to the best of my knowledge.

Certification

I certify that I have read and understand the information provided in this Healthcare BIP Intake Packet. I acknowledge that staff have explained the proposed interventions, potential risks and benefits, and alternatives. My signature below indicates informed consent for the interventions and authorizations checked above unless I have explicitly declined them.

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