Outpatient Therapy Forms

Outpatient Therapy Forms
Name*

FIRST NAMELAST NAME
MI
SOCIAL SECURITY NUMBER*
DATE OF BIRTH*

MonthDayYear
Date
Address*

MAILING ADDRESS

Street Address Line 2

CITY, STATE, ZIP CODEState / Province

Postal / Zip Code
HOME PHONE
MOBILE PHONE
EMAIL
example@example.com
Preferred method of contact for reminder calls and other electronically generated
If voice, please select preferred number

HomeMobileWork
messages (please select multiple options):
Email

messages (please select multiple options):VoiceText
MARITAL STATUS*

MarriedSingleDivorcedSeparatedWidowedOther
EMERGENCY CONTACT NAME*
Type a question*

MaleFemaleOther
EMERGENCY CONTACT NUMBER*
EMERGENCY CONTACT RELATIONSHIP TO CLIENT*
REASON FOR REQUESTING SERVICES*
REFERRAL SOURCE*

CAPITOL AREA ASAPJOHN TYLER ASAPCOURTATTORNEYPROBATION AND PAROLECOMMUNITY CORRECTIONSOTHER CRIMINAL JUSTICEHOSPITALTREATMENT CENTERMAT CLINICMAT PHYSICIANPSYCHIATRYTHERAPISTOTHERRECOVERY ORGANIZATIONEMPLOYMENTSCHOOLOTHEROTHER
FAMILY/FRIEND
NAME OF REFERRAL SOURCE (IF ASAP, CASE MANAGER)
CONTACT NUMBER FOR REFERRAL SOURCE
PRIMARY INSURANCE AND PAYMENT INFORMATION
INSURANCE COMPANY NAME*
INSURANCE POLICY NUMBER*
INSURANCE ID NUMBER
POLICY HOLDER NAME*
POLICY HOLDER SOCIAL SECURITY NUMBER*
POLICY HOLDER DATE OF BIRTH*

MonthDayYear
Date
POLICY HOLDER ADDRESS
SECONDARY AND OTHER INSURANCE AND PAYMENT INFORMATION
INSURANCE COMPANY NAME
INSURANCE POLICY NUMBER
INSURANCE ID NUMBER
OTHER BEHAVIORAL HEALTH CLINICIAN
BEHAVIORAL HEALTH CLINICIAN NAME
BEHAVIORAL HEALTH CLINICIAN NOT LISTED:
BEHAVIORAL HEALTH CLINICIAN ADDRESS
BEHAVIORAL HEALTH CLINICIAN PHONE NUMBER
PRIMARY CARE PHYSICIAN NAME
PRIMARY CARE PHYSICIAN ADDRESS
PRIMARY CARE PHYSICIAN PHONE NUMBER
IF BHC OR PCP IS LISTED PLEASE COMPLETE A RELEASE OF INFORMATION OR NOTATE REFUSAL HERE*
RCIC Outpatient Intake Packet 2/16/22
RIVER CITY CLIENT ORIENTATION CHECKLIST §690
- Care Coordination: Behavioral Health Clinician and Primary Care Physician Consent or Refusal
  • Policy: Attendance, Cancellation, Insurance and Payment, & Credit Card
  • Release of Liability
  • COVID-19 Addendum
  • Client Consent
  • Release of Information: We do not release any information without a signed release except in the case of a court subpoena or as requested by your insurance company or referral/funding source.
  • Schedule of Fees
  • Authorization for Credit Card Use
• Program and Client Handbook
• Freedom of Choice and Title VI of the Civil Rights Act of 1964 Statements
Advanced Directive
• Grievance Policy: Human Rights Policies and Reporting Violations
• Notice of Privacy Practices: Protected Health Information
• General Policies and Procedures: Hours and days of operation, Emergency contact
numbers, After-hour services, Weapons, Tobacco, Inclement weather, Financial and Fee for service policies
• General Policies and Procedures: Behavior Management Policy
• General Policies and Procedures: Emergency Preparedness and Fire Safety
• General Policies and Procedures: Building Layout and Evacuation Plans Program Specific
Policies and Procedures: Program Handbook/Parental Support
• Program Specific Policies and Procedures: Urine Drug Screening Policy/Procedures
• Staff Introduction and Contact Information

I, the undersigned, do agree that the contents of the client orientation as well as other programs and services have been thoroughly explained to me by River City Counseling Group Services and that you have read, understand, received, and attest to the corresponding sections outlined above.
Client Printed Name
Signature

Clear
Date

MonthDayYear
Date
LG/AR Printed Name
Signature
Date

MonthDayYear
Date
AUTHORIZATION FOR THE RELEASE OF INFORMATION
Section I:
Client's Name*
SS Number*
DOB*
Name of Person and/or Program Releasing Information*
Address
Email
example@example.com
Phone
Fax
Name of Person and/or Program Receiving Information:

RIVER CITY COMPREHENSIVE COUNSELING SERVICES, INC P: 804.230.0999 F:804.230.0998 RIVER CITY INTEGRATIVE COUNSELING SERVICES P: 804.230.0999 F:804.230.0998 RIVER CITY RESIDENTIAL SERVICES, LLC P: 804.799.9001 F: 804.799.1533
Section II: PURPOSE OF INFORMATION / INFORMATION TO BE RELEASED

Healthcare information relating to a Mental and Behavioral Health ConditionAll Healthcare information Medical history, Hospitalizations, Medication, etcAcademic/School Records, Psychological/Achievement TestsEmergency ContactRecovery Oriented Systems of Care (Recovery Community Organization)Information related to Legal Involvement (Probation, Parole)Other
Section III: INFORMATION WILL BE TRANSMITTED VIA:

MailFaxEmailVerbalFace to Face DeliveryPick UpOther
Section IV: AUTHORIZATION:
The Execution of this form does not authorize the release of information other than that specifically described above. The information requested on this form is solicited under

Title 38, U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act 42 CFR Part 2, 45 CFR Parts 160 and 164, 5 U.S.C. 552A, and 38 U.S.C. 5701 and 7332 that you specify. Recipients of this information are forbidden from Re-Disclosure without the specific further information authorization as cited by the code of Federal Regulations Section 2.31 of PI.L 93-282 42 Part 2. I Understand that this Authorization may be withdrawn at any time in writing, except to the extent that the agency or the person who is to make the disclosure has already acted in reliance on it. This authorization will remain in effect for a maximum of 365 Days after I sign and date the form below, unless the purpose of this authorization is to maintain ongoing communication in order to enhance continuity of care, in which case it will remain current throughout the duration of enrollment and expire 90 days from the date of discharge from services. I understand that this authorization is voluntary and that I

may refuse to sign this form. My refusal to sign will not affect my ability to obtain treatment.
AUTHORIZATION FOR THE RELEASE OF INFORMATION
Section V: Signature Page
Client Printed Name*
Signature*

Clear
Date*

MonthDayYear
Date
Date

MonthDayYear
Date
Legal Authorized Representative Signature
Legal Authorized Representative Signature
Should be Empty:

Outpatient Therapy Forms

PRIMARY INSURANCE AND PAYMENT INFORMATION

SECONDARY AND OTHER INSURANCE AND PAYMENT INFORMATION

OTHER BEHAVIORAL HEALTH CLINICIAN

BEHAVIORAL HEALTH CLINICIAN NOT LISTED:

RIVER CITY CLIENT ORIENTATION CHECKLIST §690

AUTHORIZATION FOR THE RELEASE OF INFORMATION

Section I:

Section IV: AUTHORIZATION:

AUTHORIZATION FOR THE RELEASE OF INFORMATION

Section V: Signature Page