Behavioral Health Center New Client Forms

Demographic Information
Patient Name*
Date of Birth*

MonthDayYear
Date
Age*
Sex*
Marital Status*
Today's Date*

MonthDayYear
Date
Address*

Address

Street Address Line 2

CityState

Zip Code
Spouse's Name
Home Phone*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Name
Preferred Pronoun
Employer Name/School
Occupation
Primary Care Physician Name and Address*
YesNo
If yes, provider name and address:
Responsible Party & Emergency Contact Information
Guardian Name
Relationship to Client
Address

Address

Street Address Line 2

CityState

Zip Code
Date of Birth

MonthDayYear
Date
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Emergency Contact*
Relationship to Client*
Phone Number*
Format: (000) 000-0000.
Insurance Information
YesNo
MaineCare Number
YesNo
Primary Insurance
Policy Number
Group Number
Name of Insured
Relationship to Client
Date of Birth

MonthDayYear
Date
Employer
Occupation
Other Insurance
Policy Number
Group Number
Name of Insured
Relationship to Client
Date of Birth

MonthDayYear
Date
Employer
Occupation
BILLING POLICY
I understand that I am financially responsible to Behavioral Health Center for services not covered by my insurance and/or MaineCare.
Patient/Guardian Signature*
Date

MonthDayYear
Date
I hereby authorize Behavioral Health Center to furnish information regarding my diagnosis and treatments for billing purposes to the above insurance carriers and/or MaineCare.
Patient/Guardian Signature*
Date

MonthDayYear
Date
CONSENT FOR TREATMENT
I hereby authorize permission for treatment by providers of Behavioral Health Center.
Patient/Guardian Signature*
Date

MonthDayYear
Date

YesNo
YesNo
YesNo
YesNo
This is your space to provide a little background on why you are reaching out and looking for services.

0/500
Yes

CLIENT INFORMATION
Behavioral Health Center (BHC) provides a wide range of excellent counseling and mental health services by well trained, qualified, and licensed professionals. Your treatment will include an initial assessment, development of a treatment plan, and evaluation of your treatment experiences. We ask you to provide your doctor's name and to allow us to talk with your doctor when appropriate to coordinate your treatment. BHC uses brief therapy techniques when appropriate. Please feel free to discuss any questions about your treatment with your therapist.

Check In: Please remember to check in with the receptionist upon arrival and when leaving. It is important thatany co-pay or deductible is paid at the time of service. Without payment we are unable to provide treatment. Please update us with any changes to your address, phone number, and/or insurance company.

Confidentiality: BHC treatment services are confidential except in certain circumstances. You must give permission for us to speak to anyone about you. We must report to the Department of Health and Human Services information we obtain about neglect, exploitation, and abuse of children and dependent or incompetent adults. We will make efforts to warn and protect any intended victims of violence. We will attempt to protect you if we believe you may hurt yourself. We will attempt to discuss our concerns with you, and include you in our planning. BHC abides by the rules of HIPAA as explained in our Notice of Privacy Practices.

Minors: Your therapist will decide what information to share with parents of children. We consider the child's need for confidentiality, and the needs of parents to fulfill their responsibility to protect and nurture a child. Please discuss any concerns you have with your therapist. Parent or Guardian will be required to remain on premises during the child's session, for safety purposes.

Peer/Family Support: Your therapist has resources available to you about support services.

Quality Improvement: In order to assess how successfully we are serving you, we will ask you annually to complete a survey. We thank you for your cooperation.

Reminders: To better serve you, we will call or text to remind you of your next scheduled appointment. This is a generic call or automated text and will not disclose the name of our facility or the nature of our business.

Winter Weather Cancellations: Please call the office at 207-941-0879 for telehealth options.

Emergency/Urgent Care: We provide 24-hour phone services for urgent needs. If you have not madespecific arrangements with your therapist, there are therapists on call. Please call our office at (207) 941-0879 (please call (207) 992-0863 if no answer A therapist will return your call, usually within two hours. If you have a life- threatening emergency please call 911 or go to your local emergency room. For non-life-threatening situations, you may call PHONE HELP at 1-888-568-1112.

Parking: Clients may park in the lot at the rear of the building. You may also park on the street, but please take note of special winter parking regulations; Bangor allows parking on the even numbered side of the street on even numbered days and the odd numbered side of the street on odd numbered days between November 1 and March 31. The police strongly enforce these regulations on Court Steet. Any fees incurred will be the responsibility of the vehicle owner.

OUR FINANCIAL POLICY

Thank you for choosing Behavioral Health Center as your mental health provider. We are committed to your successful treatment. Please understand that payment of your co-pay, deductible, or other fees are considered part of your treatment.

Payment of co-pay, deductible or non-covered services are due prior to services being rendered. BHC accepts Cash, Debit, Check, Master Card, Visa and American Express

Insurance: If we are contracted with your insurance, we will bill your insurance and you are responsible for any co-pay, deductible, or non-covered services at the time services are rendered. We must have your current insurance information at the time you are being seen, or you will be required to pay in full. Your insurance policy is a contract between you and your insurance company. We are not party to that contract. In the event we do not accept assignment of benefits, it is your responsibility to get pre-approval for services. If your insurance has not paid your account in full, within 60 days, the balance will become your responsibility. Please be aware that some, and perhaps all, of the services provided may be non- covered services and not considered reasonable and customary under your insurance and/or Medicare or MaineCare program. If there is a change to your insurance you must notify us immediately.

MaineCareClients: We provide most services paid for by the MaineCare insurance program. MaineCare regulations only allow you to see one therapist at a time. Therefore, please advise your therapist if you are currently receiving other services, or have received services, by a mental health clinician during the current calendar year.

Reasonable and Customary Rates:

Service Description	Rate	Session Length
Initial Assessment	$150.00	50 minutes
Individual & Family Psychotherapy	$130.00	50 minutes
Group Psychotherapy	$65.00	90 minutes
Forensic Services/Court Appearance	$120.00	Per Hour
Report Preparation and Report Writing	$500.00	Per Hour
Other Fees
No Show and Cancellation Fee	$130.00	Per Occurence
Return Check Fee	$30.00

Collection Accounts – A collection fee of 30% will be added to the existing balance.

Minor Clients: The adult accompanying a minor (parent(s)/guardian) is responsible for payment at the time of services. Behavioral Health Center will not bill a third party for payment.

Missed Appointments: Unless canceled, at least 24 hours in advance, there will be a charge of $130.00. Please help us serve you better by keeping your scheduled appointments.

Delinquent Accounts: Accounts over 90 days, without payment arrangements, will be referred to collections. A collection fee of 30% will be added to the existing balance.

I have read, had the opportunity to ask questions, and been given a copy of this information.

Signature of Patient*
Date

MonthDayYear
Date
Signature of Guardian*
Relationship to client

Consent to Use and Disclose Your Health Information
This form is an agreement between you, Client/Guardian* and Behavioral Health Center. When we use the word "you" below, it can mean you, your child, or a person whom you are the legal guardian of, if you have written his or her name here: Client .

When we examine, test, diagnose, treat, or refer you we will be collecting what the law calls Protected Health Information (PHI) about you. We need to use this information to decide what treatment is best for you, and to provide you with this treatment. We may need to share this information with others who provide treatment to you, need to arrange payment for your treatment, or for other business or government functions. In most cases, as defined in our Notice of Privacy Practices, your written consent will be needed to disclose your PHI.

Your PHI may include: records covered by federal rules governing confidentiality of alcohol and drug abuse treatment programs; records covered by state rules governing mental health services; and records concerning you, or your child's, diagnosis or treatment for HIV or AIDS.

By signing this form, you are agreeing to let us use your information here and to send it to others. Our Notice of Privacy Practices explains in more detail your rights, and how we can use and share your information.

If you do not sign this consent form agreeing to what is in our Notice of Privacy Practices, we cannot treat you.

In the future we may change how we use and share your information and therefore may change our Notice of Privacy Practices. If we do change it, you can get a copy from our Privacy Officer.

If you are concerned about some of your information, you have the right to ask us not to use or share some of your information for treatment, payment, or administrative purposes. We require all requests to be in writing. Although we will try to respect your wishes, we are not required to agree to these limitations. However, if we do agree, we promise to do as you asked.

After you have signed this consent, you have the right to revoke it (by writing a letter to our Privacy Officer telling us you no longer consent) and we will comply with your wishes about using or sharing information from that time on but we may already have used or shared some of your information and cannot change that.

By signing below, you are confirming you have read the above and received a copy of our Notice of Privacy Practices.
Signature of client or his or her personal representative*
Date

MonthDayYear
Date
Printed name of client or his or her personal representative
Relationship to client

Outpatient Services
Rights of Recipients of Mental Health Services who are Adults/Children in Need of Treatment

The following is a summary of your rights as a recipient of outpatient (nonresidential) services under the Rights and Recipients of Mental Health Services. You may receive a copy of the Rights of Recipients of Mental Health Services booklet from our office or from the Department of Behavioral & Developmental Services, 40 State House Station, Augusta, Maine 04333 (287-4200 or TTY 287-2000 If you are hearing impaired or do not understand English, an interpreter will be made available to assist you understanding your rights.

1. Basic Rights: You have the same civil, human, and legal rights, to which all citizens are entitled. You have the right to be treated with courtesy, respect, and dignity.

2. Right to Confidentiality and Access to Records: You have the right to have your records kept confidential; to be released only with your informed and signed consent. (Specific circumstances where the agency can release or share information as described in the Rights book You have the right to review your record at any reasonable time, and to add written comments to clarify information you believe is inaccurate or incomplete.

3. Right to an Individual Treatment Service Plan: You have the right to a written service plan, developed by you and your worker, based on your needs and goals. The plan must: be based on your actual needs; identify how a need will be met if the service is not available; include tasks to be completed, and by whom; time frames for accomplishment of tasks and goals; and criteria to determine success. If you do not agree with the plan, you have the right to request and receive a second opinion. You have a right to a copy of the plan.

4. Right to Informed Consent: No service or treatment can be provided to you against your will. You have the right to be informed of possible risk and anticipated benefits of all services and treatment. You may designate a representative who is authorized to help you understand and exercise your rights, help you make decisions, or to make decisions for you. The guardian also has the right to be fully informed.

5. Right to File a Grievance and Appeal: You have the right, without retribution, to grieve any violation of your rights or any questionable practice. You have the right to a written response, including reasons for the decision. You may appeal the decision to the Department of Behavioral & Developmental Services. For assistance contact: Office of Advocacy, 60 State House Station, Augusta, Maine 04333 (287-2205) or Disability Rights Center, P.O. Box 2007, Augusta, Maine 04333 (1-800-452-1948)
Client*
Date

MonthDayYear
Date
Guardian*
Date

MonthDayYear
Date

Behavioral Health Center Cancelation/No Show Policy

Thank you for trusting Behavioral Health Center with your mental health needs, we are here to help! While we understand that life can be unpredictable at times, we kindly ask, should you need to cancel or reschedule an appointment, that you provide 24-hour notice. By providing us with advanced notice we are able to schedule other clients who may be waiting for an appointment. In keeping with our goal of providing the best patient care to all of our clients we ask that you please review our Cancelation/No Show Policy below:
- Effective March 1, 2023; any established client who does not show for an appointment, or cancels or reschedules an appointment with less than 24-hour notice, will be considered a No Show and will be charged the full cost of their session, $130.00, billed to the client, not the insurance.
- In addition to the above stated fee, for an established client, within any 12-month period, the first No Show will result in removal from the recurring schedule. The second No Show will result in the client being placed on a same-day scheduling basis and the third No Show will result in the discharge of the client. (Please be mindful of tardiness, as excessive lateness may result in discharge as well)
- Any new client who does not show for their first appointment, or cancels or reschedules that appointment with less than 24-hour notice will be automatically placed at the bottom of our wait list and will be required to pay for their first session in advance.
- For your convenience Behavioral Health Center does try to provide call/text reminders 48-hours ahead of scheduled appointment times, however, should a client not receive a reminder the above stated Policy will remain in effect.
Again, we understand that life happens and that we all experience unforeseen emergencies from time to time that keep us from maintaining scheduled appointments. Should this happen, please contact our Office Manager, who may be able to waive the Cancelation/No Show fee. You may contact Behavioral Health Center 24-hours a day, 7 days a week, at (207) 941-0879, to let us know of any scheduling changes. Should you reach our answering service please leave a detailed message and we will return your call at our earliest convenience.
X
Signature*

Credit Card On File Policy & Agreement

Behavioral Health Center (BHC) has adopted a new credit card policy; effective March 3, 2023, all clients with private insurance, or who are self-pay, will be required to keep a credit, debit or HSA card on file. We understand that some clients, for legitimate reasons, may not have a credit, debit or HSA card, and in such situations payment will be expected prior to services being rendered. This policy will help to ensure that balances are paid on time and will make payment of your bill much easier. If you have checked-in to a hotel, or used a car rental service, you will be familiar with a Credit Card On File policy (CCOF).

To safeguard your card information against electronic theft or lose of data integrity, your information will not be stored electronically, but will be stored securely on-site, in accordance with our HIPAA-compliance standards. Your card's security code will not be required or kept on file. Your card information will be used to process the cost of your session and will be processed via our HIPAA-compliant payment system. If you are a self-pay client this will be the full cost of your session. If you have private insurance our office staff will inform you of your financial responsibility before processing payment. It may be necessary that you are charged the full rate of your session until your insurance has been adjudicated, at which time you will be contacted with your updated policy rates and any credits on your account refunded.

Your card information will be processed within five (5) business days of the date of service for your session. Keeping your card information on file does not in anyway infringe upon your rights as a card holder. You may at any time dispute a charge made to your card or question your insurance company 's decisions. If you have any questions or concerns regarding this policy, please contact our office staff at (207) 941-0879.

Your card information will only be used for the following purposes:
- Session payments not collected at the time of your visit
- No show or cancellation fees
- Insurance discrepancies
- Any outstanding balances 31 days beyond the date of service
By signing below, I authorize Behavioral Health Center to keep my signature and my card information securely on-file. I further authorize Behavioral Health Center to charge my card for any of the aforementioned purposes.
Cardholder Signature*
Date

MonthDayYear
Date
Signature of Guardian*
Relationship to client
Should be Empty:

Demographic Information

Responsible Party & Emergency Contact Information

Insurance Information

BILLING POLICY

CONSENT FOR TREATMENT

CLIENT INFORMATION

OUR FINANCIAL POLICY

Consent to Use and Disclose Your Health Information

Outpatient Services Rights of Recipients of Mental Health Services who are Adults/Children in Need of Treatment

Behavioral Health Center Cancelation/No Show Policy

Credit Card On File Policy & Agreement

Outpatient Services
Rights of Recipients of Mental Health Services who are Adults/Children in Need of Treatment