Therapy Intake Form Logo

  • Inspiring Change Mental Health Services, LLC

  •  -

  • If yes, where was the last place you received treatment? How long did you receive treatment for at that location?

  • If so, what is or was your drug(s) of choice?



  • Please provide us with the number of self-help groups you have attended here.

  • Financial Information

  • Browse Files
    Cancelof

  • Personal History

  • History of the Present Problem

  • The Therapy Process

  •  Working with you to identify presenting issues and develop a plan of care is the goal. However, it is your commitment to identifying personal goals towards which you desire to move and obstacles which may prevent that movement which will, in large part, determine the success of the therapy. If you have a crisis situation develop after hours, call the suicide prevention hotline at 988 or go to your local emergency room.

     

     

  • Legal Responsibility

  • Under the laws of the United States and the state of Maryland your Personal Health Information (PHI) must be kept private. It is also required by law to give you this notice and to follow the terms of this notice while it is in effect.

     

    Changes in these privacy practices are allowed at any time as long as those changes are permitted or required by law. Any changes in these privacy practices will affect how the privacy of your PHI is protected, including any PHI received about you or created in the course of your therapy. These changes could also affect the protection of the privacy of any of your PHI received before the changes. If changes are made, a new notice will be available to you.

  • Use and Disclosure of your Personal Health Information (PHI)

    Please read and sign

  • Coordination with State of Mind Health and Wellness - Medication Management Services

    If you agree to medication management services at any time during your care with Inspiring Change Mental Health Services, you consent to the sharing of your health record with State of Mind Health and Wellness. This coordination ensures the delivery of medication management services and integrated care. State of Mind Health and Wellness has signed a Confidentiality Agreement and a Business Associates Agreement with Inspiring Change Mental Health Services.  This ensures that the agency is maintaining compliance with HIPAA regulations regarding your health information. If you are currently seeking Medication Management Services, please read and sign our Medication Management Form.

    Consent to Communicate with Carelon Behavioral Health Systems- Medicaid Insurance Recipients Only

    The purpose of this section is to give Inspiring Change MHS, as your provider, permission to share and bill specific information about your care with Carelon Behavioral Health. Carelon Behavioral Health serves as Maryland's Administrative Services Organization (ASO) for Medicaid participants receiving behavioral healthcare. Without your signed authorization, we will be unable to share this information, which could delay your access to certain services. This information we shared allows Carelon to:

    • Approve and authorize the behavioral health services you need, such as therapy, psychiatric rehabilitation services or medication management.
    • Manage claims and billing so that your services are covered appropriately.

    Billing Information and Availity Clearinghouse- Medicaid Only 

    All participants’ medical billing claims will be processed through Availity. Availity is a medical billing and claims clearinghouse approved by Carelon Behavioral Health Systems, Carelon uses Availity to ensure that claims are processed efficiently while maintaining compliance with HIPAA regulations regarding your health information. Inspiring Change Mental Health Services will bill your insurance company for all sessions unless otherwise agreed upon. The information that will be shared with Availity is:

     

  • Clear

  • Signature and Submission

  • If you are a referring agency, please mark below to confirm that your client is aware of the referral being made to Inspiring Change MHS on thier behalf. Additionally, they have agreed to be contacted for an intake via phone, email or text message.

  • Clear

  • The parent or legal  guardian must type and sign their name below. Please provide proof of guardianship at the time of your assessment. If you are a referring agency, please skip this section. 

  • Clear
  • Browse Files
    Cancelof
  • Reload
  • Should be Empty: