Archer Angels Family Services

Patient Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth (DOB):*

Date

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Gender*

Primary Language*

Interpreter Needed?*

YesNo

Name of Health Insurance Plan:*

Member & Group Identification Number:*

Copay Amount:

Name on Card:

Credit/Debit Card #:

Expiration Date:

Security Code on Back (3 Digits):

Name of Parent/Legal Guardian:

Home Address & Contact Phone Number (Home/Work/Cellphone#):

Date of Last Physical Exam:*

Date

Allergies:*

Medical Provider Information (PCP): Name of Hospital/Group/Provider, Phone Number, Address*

Emergency Contact: (Relationship to Patient, Name, Contact Phone Number, Address*

Consent to Treatment

I consent to receive outpatient psychotherapy services from Archer Angels Family Services commencing on:

I consent to receive counseling services via Telehealth Distance Counseling. I am aware that I will share my perspective, personal and medical history, as well as receive therapeutic supports. These therapeutic services are voluntary and include assessments/evaluations, mental health counseling, talk therapy, psych-education, community resources, and referrals.

By signing below, I fully agree to participate in sessions via telehealth to work towards achieving progress and goals according to my treatment plan.

Acknowledgment of Receipt:

I acknowledge that I will receive a copy of the following documents and my questions were answered regarding these, at the commencement of services:
 HIPAA/Privacy Policies
 Notice of Patient Practices (NPP)
 Office Policies, Agreement & General Information
 After-Hours Emergency Policy
 Appointment & Safe Space Policy

Patient Name*

First NameLast Name

Patient Signature: (Parent/Guardian signature if patient is a minor)*

Print Name Signed Above: (Parent/Guardian)*

Medical Release Form

By signing this authorization form, I understand that regulations require this organization to request client physical examination information as part of treatment. I consent to the disclosure of my individually identifiable health/medical record to my primary care provider. I grant Archer Angels Family Services, LLC permission to release and receive information from my provider(s) regarding my past, present and future health condition as well as treatment. This will be done in a manner consistent with state and federal laws concerning the privacy policy. I authorize bilateral communication between parties regarding my individually identifiable health information.

Patient Name:*

First NameLast Name

Date of Birth (DOB):*

Date

Patient Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Phone Number:*

Please enter a valid phone number.Format: (000) 000-0000.

Insurance Member ID Number #:*

Date of Last Physical:*

Date

Physician Name:*

Health Center/Medical Practice Facility Information: (Location Address, Phone Number & Fax Number)*

I authorize the release of the following information:*

Medical Record (Physical Exams, Medication, Test Results, Reports)Mental Health Record (Psychiatric Evals, Psychotherapy Notes, Treatment plans)Substance or Alcohol Use (History, Testing and Treatment)Information pertaining to AIDS or HIV statusCare Coordination & Case ManagementOther Records:

Patient Name:*

First NameLast Name

Patient Signature: (Guardian Signature if patient is a minor)*

Print Name Signed Above: (Parent/Guardian)*

Release of Information

Name

First NameLast Name

Date of Birth: (DOB)

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth: (DOB)

Date

I consent to the provider, Archer Angels Family Services, to

Obtain my PHI from this third partyDisclose my PHI to this third party

Name of Third Party: (Facility, Agency, School, Therapist, Provider, Relative, etc)

Contact Person 1:

Contact Person 2:

Facility Address/Location:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:

Fax Number:

I authorize the release of the following information:

Psychiatric/Psychological Assessments, Evaluations, and/or TestingSchool RecordsTreatment Summary/Treatment PlanCare Coordination & Case ManagementDrug/Alcohol Diagnosis, Treatment or Referral InformationAttendance RecordsEducational TestingDischarge SummaryOther Records (Specify):

Patient Name

First NameLast Name

Patient Signature: (Parent/Guardian Signature if patient is a minor)

Print Name Signed Above:

Thank you for choosing Archer Angels Family Services!

Please review the AAFS Terms & Conditions. Accepting these terms is a requirement to submit this e-form.

Signature*