Adult Intake Form - Dominion Behavioral Healthcare

If you are human, leave this field blank.

Mental Health History

Have you received counseling, psychological, or psychiatric services in the past? *

Yes

If yes please provide the Professional’s Name and dates of treatment below:

Name of Professional

Service Began

Services Ended

Name of Professional

Service Began

Services Ended

Have you ever been hospitalized for mental health reasons? *

Yes

If yes, when?

Where?

Length of Stay

Reason for Hospitalization

Medical History

Primary Care Physician

Office Address

City

State

Zip

Office Phone #

Fax #

Please list ALL current medications:

Medication

Dosage

Prescribing Doctor

Medication

Dosage

Prescribing Doctor

Medication

Dosage

Prescribing Doctor

Emergency Contact

Their Name

Relation

Home Phone #

Cell Phone #

Responsible Party (if different from patient)

Name

DOB

Relation to Patient

SSN

Billing Address

City

State

Zip

Contact #

Employee Assistance Program (EAP)

Are these visits covered by Employee Assistance Program (EAP) benefits?

Yes

If yes, please provide the following information:

Name of EAP company

Authorization #

Allotted Number of Visits

EAP Start Date

EAP End Date

Primary Insurance

Insurance Company *

Policy ID# *

Policy Holder *

Select One: *

Male

Female

OtherOther

DOB *

Relation *

Address *

City *

State *

Zip *

Insurance Contact # *

Secondary Insurance

Insurance Company

Policy ID#

Policy Holder

Select One:

Male

Female

DOB

Relation

Address

City

State

Zip

Insurance Contact #

Please Select One:

Insurance information provided *

I hereby authorize DBH to release necessary medical information to my insurance company. I further authorize direct payment to the above entities from the above listed company. I understand that I am responsible for obtaining referrals, if necessary, and paying and co-payment, co-insurance, or deductibles required by my Plan. I also understand that I may be responsible for the full amount in the event of non-coverage determined by my plan. If my account is not paid when due, I further agree to pay any collection expenses upon my account being turned over to the Credit Adjustment Board. I further understand that it is my responsibility to notify DBH when/if my insurance changes.

No insurance information provided

I agree to pay in full by check, credit or money order at or before the date of service. If my account is not paid when due, I further agree to pay any collection expenses upon my account being turned over to the Credit Adjustment Board.

I understand that the following charges are not covered by insurance: $20-Medication Refill Fee, $75-No Show/Late Cancellation Fee (we require 24 hours notice for a cancellation) $125-Bariatric Form Writing Fee. $120 (per hour)-Completion of Paperwork/ Letter Writing Fee. For other fees not covered by insurance please refer to the financial agreement. l I further understand that I may request a full copy of DBH’s financial agreement at any time.

Patient Signature *

Date *

Have you had any of the following problems in the last month?

Please explain briefly your reason/reasons for seeking help at this time

Please provide any additional information that you believe may be helpful

Please list any areas that you would like to discuss in therapy:

Consent for Treatment

I, the undersigned, do voluntarily consent to psychiatric/behavioral health assessment and/or treatment for myself.

By signing below, I authorize Dominion Behavioral Healthcare to provide psychiatric and/or behavioral health assessment and exams, treatment, and/or diagnostic procedures which now, or during the course of my treatment, become advisable. I understand that the purpose, potential risks and benefits, and alternatives to any treatment, as well as the risks of not having treatment, will be explained to me upon my request, and that I can always decline treatment.

I understand that while my treatment will be designed to help me, there is no guarantee of a successful outcome.

Psychotherapy involves risks, such as but not limited to, the development or worsening of emotions such as anxiety, sadness and anger. I understand that this is a normal response to working through life experiences and that these reactions should be discussed with my therapist or physician.

Treatment with Medication also has certain risks, varying with the type of medication prescribed, which will be explained to me. I know that taking a medication of any kind always carries the risk of a potentially fatal allergic reaction. I understand that it is my responsibility to make my physician aware of any health conditions that I have or that develop over the course of treatment, and to make my physician aware of any other medications, including over-the-counter medications or herbal supplements that I am taking. I also understand that discontinuation of medication should be discussed in advance with my physician.

I understand that it is my responsibility to inform my physician or therapist if I feel worse in response to any treatment provided, including but not limited to, the development or worsening of suicidal ideation, depression, agitation, anxiety, insomnia, irritability or mania, especially if these reactions are new, severe, or abrupt in onset.

I understand that as part of my mental health care, Dominion Behavioral Healthcare originated and will maintain paper and/or electronic records describing treatment, testing results and forms, correspondence and insurance information. Except when required by law, this information cannot be disclosed without my written consent. I may revoke any authorization for disclosure at any time except if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

I further understand that I may request a complete copy of Dominion Behavioral Healthcare’s Privacy Practices at any time.

I understand that my treating clinician is required by law to maintain privacy of my mental health record and to provide me with notice of their legal duties and privacy practices with respect to my mental health record. The treating clinician has the right to change those privacy policies and practices with notification to you in writing.

I understand that at no time, am I permitted to record video and/or audio of my sessions with my treating clinician.

I understand that I have the right to disagree with decision made and I can make a formal complaint to a Dominion Behavioral Healthcare Privacy Officer at (804) 270-1124. A written complaint can be made to the Secretary of the U.S. Department of Health and Human Services.

I understand that this notice is in effect beginning January 1, 2018. If there are any changes to this notice while I am still in treatment at DBH then I will be notified in person and writing about such changes.

I acknowledge that I have been notified of the HIPAA policy and may request a complete written copy at any time.

Patient Signature

Date

Authorization to Release Information

In accordance with HIPAA privacy laws, a signed consent form is required to release information in any form about your care. This authorization allows us to communicate when needed or requested regarding scheduling, insurance or billing information, as well as routine or emergency contact. This authorization may be rescinded or amended at any time that you choose.

I certify that I am 18 years old or older and give permission for Dominion Behavioral Healthcare to communicate with the following persons about my treatment:

Please use the space below to identify any family, friend or medical professional with whom you may want us to have contact.

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

I DO NOT authorize DBH to release any information.

Please initial

Patient Signature

Date

Consent for Coordination of Care

PATIENT NAME

DATE OF BIRTH

*In order to provide the best care possible, your physician and/or clinician would like to be able to communicate with your other treating medical professionals.

*Most insurance companies require this information exchange.

*Please check one of the following and sign.

I give Dominion Behavioral Healthcare permission to exchange my protected health information to the following providers:

Primary Care Doctor’s Name

Phone #

Fax #

Address

Psychiatrist’s Name

Phone #

Fax #

Address

Psychotherapist’s Name

Phone #

Fax #

Address

Please indicate one:

I WAIVE NOTIFICATION of my PCP that I am seeking or receiving mental health services, and I direct you NOT to so notify him/her.

I do not have a PCP and do not wish to see or confer with one. I therefore WAIVE NOTIFICATION of a PCP that I am seeking or receiving mental health services.

Signature

Date

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Patient Demographics

Mental Health History

Medical History

Emergency Contact

Responsible Party (if different from patient)

Employee Assistance Program (EAP)

Primary Insurance

Secondary Insurance

Have you had any of the following problems in the last month?

Lifestyle Questions

Consent for Treatment

Authorization to Release Information

Consent for Coordination of Care

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