Healthcare Initial BASP

Healthcare Initial BASP

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance / Payment

Policy Number:    Group Number:

Presenting Concerns / Referral Information

Medical & Psychiatric History

Risk Assessment

Suicidal ideation or intent: Yes No

Homicidal ideation or intent: Yes No

Functional Status & Social Information

Initial Assessment: Goals & Proposed Interventions

Anticipated frequency:    Anticipated duration:

Consent for Assessment and Treatment

I, the undersigned, authorize the clinician(s) and administrative staff associated with the Baseline Assessment and Service Plan (BASP) to perform assessment, treatment planning, and clinical services as described above. I understand that assessment and treatment may include clinical interviews, standardized measures, behavioral observation, therapeutic intervention, and coordination with other providers as necessary.

By signing, I acknowledge I have been informed of the nature of the assessment and treatment, potential benefits, potential risks or discomforts, reasonable alternatives, and the anticipated course of care. I understand I may withdraw consent at any time, subject to clinician obligations to ensure safety and continuity of care.

I consent to the exchange of information with other health care providers, schools, and payors when necessary for coordination of care or as required for billing. Exchange will be limited to information necessary for the stated purpose unless I provide additional written authorization.

I understand that confidentiality is protected by law but that exceptions include: (1) suspected child or dependent adult abuse or neglect; (2) reasonable belief of imminent risk of serious harm to self or others; (3) court order; and (4) necessary disclosures for billing and payment as described above.

I acknowledge that treatment is voluntary, and I retain the right to refuse any specific procedure or service. If I believe services are not being provided appropriately, I may request an alternative or terminate services in accordance with clinic policies.

I understand that this Initial BASP documents the assessment, initial goals, and proposed interventions and does not guarantee outcome. If conditions change, the BASP will be reviewed and amended with my involvement.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been provided with information regarding the clinic's privacy practices and my rights under applicable privacy regulations. I understand how my protected health information (PHI) may be used and disclosed for treatment, payment, and healthcare operations, and that further disclosures require written authorization unless otherwise permitted by law.

If I wish to limit the use or disclosure of my PHI, I will submit a written request. I understand the clinic will consider reasonable requests but cannot guarantee that all requests can be accommodated.

Authorization to Exchange Information (Optional)

I authorize disclosure of my health information to the following individual(s) or entity(ies) for the purpose of care coordination:

Purpose:    Limits / Expiration:

Authorization Expiration

This authorization for assessment and treatment, and for the release/exchange of information as indicated above, will expire on:    If no date is provided, this authorization will expire 12 months from the date of signature.

Provider / Assessor Information

Credentials:    Contact / Clinic:

Patient / Authorized Representative Acknowledgment

By signing below, I certify that I have read and understand the information contained in this Initial BASP. I consent to assessment and the proposed services described herein and understand my rights with respect to treatment and privacy.

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