The following documents are included:
• Intake (REQUIRED) Please complete EACH of the items. If the items do not pertain to you, please answer “N/A.,” “none,” or put a dash through the answer box.
• Guardian Authorization (REQUIRED) All persons who have custodial rights of the child MUST complete and sign the parental authorization form.
⇒ Divorced or separated parents:
If both parents do not have full custody, both parents will need to provide two parental authorization forms as well as a copy of the custody outline from the divorce/separation agreement. We only ask that the parent submit the page(s) of the document that outline the custody rights of each parent as well as the signature page —not the entire divorce decree.
⇒ Foster parents or children in the Department of Children & Families (DCF) custody:
If the child is in custody of DCF, DBH requires an ROI signed by the DCF caseworker in order to provide treatment for the child.
• PCP Release of Information (ROI) (REQUIRED) An ROI authorizes DBH to request, obtain and/or exchange documentation with outside facilities. ***When requesting medical records, please note that facilities legally have 21 days to process the request. For some cases, DBH cannot schedule an appointment until we receive the requested records. Once we receive and review the requested records, we will contact you with next steps. ***
PLEASE NOTE THAT MANY FACILITIES ACCEPT ONLY THEIR SPECIFIC RELEASE OF INFORMATION FORM. PLEASE, CHECK THE FACILITY’S WEBSITE, OR CONTACT THEIR MEDICAL RECORDS DEPARTMENT TO ENSURE THAT YOU ARE COMPLETING THE CORRECT RELEASE
• Consent to Treat (REQUIRED)- Authorizes DBH to provide treatment and/or take necessary actions to be able to provide treatment.
• Financial Agreement (REQUIRED) Responsibility of fees and charges for services provided by DBH.
• Consent for Telemedicine Services (REQUIRED) Authorizes DBH to use telemedicine in the course of your treatment.
• ID and Insurance Card (REQUIRED)- Please provide a copy of your government issued ID and the front and back of the child's insurance card.
Once completed please email the forms to email@example.com or fax to 781-465--7995 . If you fax any documents, please follow up with the Intakes Department by email or by phone to confirm our receipt of the documents.
DBH Intake Department