NW ADHD - Group Interest Form

NORTHWEST ADHD TREATMENT CENTER
Please complete the following form if you'd like to join one of our groups. Please know that if you are not a current patient at NW ADHD Treatment center, in order to join a current group, our staff will need to verify your current engagement with a behavioral health provider.
Patient Information:
Full Name*
Date of Birth*

MonthDayYear
Date
Phone*
Email*
example@example.com
Address, City, State, Zip*
Patient Insurance Information:
Patient's Insurance Provider*
Insurance ID Number*
Name of Subscriber*
Subscriber's Date of Birth

MonthDayYear
Date
Group Interest:
Please select the group(s) you are interested in joining. Select your top 2 choices. If you are interested in others, you can discuss this with our intake team when they contact you. All groups are virtual unless otherwise noted. All groups accept all insurance or self pay unless otherwise noted. (USE CTRL + Click to select multiple options)*
Consent and Acknowledgement: (Check all to ensure your interest form is processed)*

I allow Northwest ADHD Treatment Center to contact me about my interest in group therapy.By seeking engagement in group services only, I understand that I am required to have and maintain engagement with a behavioral health provider outside of Northwest ADHD Treatment Center at least for the full duration of my participation in a group at Northwest ADHD Treatment Center. I have informed my outside behavioral health provider about my participation in this group, and my outside behavioral health provider has confirmed that my participation in a group at Northwest ADHD Treatment Center is consistent with my treatment plan.I understand that my outside behavioral health provider, not Northwest ADHD Treatment Center, is responsible for my mental health care in the event of an emergency or crisis.I understand that by completing this form and participating in group therapy only at Northwest ADHD Treatment Center, I am not eligible to meet with a Northwest ADHD Treatment Center provider for individual therapy, medication management, ADHD assessment, or other services outside of group therapy. I understand that if I wish to engage in other services at Northwest ADHD Treatment Center, a separate referral form for those services, completed by my referring provider, is required. I understand that other services at Northwest ADHD Treatment Center may have significant wait times before services may become available.I understand that for attending groups that meet via a telehealth platform, I must be physically within the state of Oregon in order to participate.I have spoken with my outside behavioral health provider, and we both understand that my outside behavioral health provider will: 1. Assume full clinical responsibility for my care, and acknowledge that Northwest ADHD Treatment Center providers are not responsible for my client's care outside of group therapy. 2. Handle or provide backup services to manage client clinical emergencies. 3. Consult with Northwest ADHD Treatment Center as is appropriate, including sharing relevant clinical records, including a valid release of information for mutual coordination of care.By signing below, I acknowledge that I have read all of the information above. I am submitting this interest form for myself, or with the appropriate authority to submit this form on behalf of someone else.
By signing below, I acknowledge that I have read all of the information above. I am submitting this interest form for myself, or with the appropriate authority to submit this form on behalf of someone else.
Signature*

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Date*

MonthDayYear
If submitted by someone other than the individual who would be attending group treatment, complete the following:
Name of Individual Completing This Form
Relationship to Patient

Release of Information For Group Therapy Referral: Coordination of Care With Outside Behavioral Health Provider
EAST LOCATION: 13908 SE Stark, Suite A Portland, OR 97233 Phone: 503-255-2343 Fax: 503-255-2344

DOWNTOWN LOCATION: 1201 SW 12th Ave Suite 224 Portland, OR 97205 Phone: 971-251-9856 Fax: 503-206-6713

WEST LOCATION: 12570 SW 69th Ave, Suite 200 Portland, OR 97223 Phone: 503-427-2394 Fax: 503-454-0763
PROFESSIONALS: You are receiving this because your current patient is seeking group therapy treatment at Northwest ADHD Treatment Center, in addition to care provided by you. The purpose of this release is to enable professional communication to: coordinate care, ensure that group engagement at Northwest ADHD Treatment Center is consistent with your treatment plan, and affirm that you and your patient are aware that you are their primary mental health provider and any crises or urgent needs should be addressed through you. Please send any relevant records that may assist care coordination. Thank you.

PATIENTS: Northwest ADHD Treatment Center offers group therapy options as a means to support and enhance your current mental health treatment. In order to do this effectively, our providers need to coordinate care with your primary behavioral health provider. It is important that you are aware that your current behavioral health provider outside of Northwest ADHD Treatment Center is primarily responsible for your mental health care, including your overall treatment plan and any plans related to urgent mental health needs or crises. Please be sure you complete this form for your current behavioral health provider. If you do not have a current behavioral health provider, you may not be able to participate in group therapy at Northwest ADHD Treatment Center. If you would like us to receive records or communicate with other professionals, agencies, or individuals, please complete a separate version of this form.

AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

For offices submitting records: Fax is the preferred means for NW ADHD to receive records.
Patient Name*
Date of Birth*

MonthDayYear
Date
This release is valid for other behavioral and medical clinicians at Northwest ADHD Treatment Center who may provide care to the above mentioned patient.

Personal health records will be made available to you through your patient portal account. If you would like your personal health records provided in a different way, please note how you would like to receive them above.
CHECK ALL OPTIONS THAT APPLY:*

I authorize NW ADHD Treatment Center to REQUEST records and OBTAIN information FROM the party listed belowI authorize NW ADHD Treatment Center to SEND records and PROVIDE information TO the party listed belowVerbal communication only - No exchange of records
Current Behavioral Health Provider Information
Current Behavioral Health Provider*
Provider Address*
Provider Phone Number*
Provider Fax Number
INFORMATION WHICH MAY BE USED/ DISCLOSED:
Place Initials In The Box For Each Type of Information That You Consent To Share:
ALL RECORDS AND INFORMATION RELATED TO MY MENTAL HEALTH CARE
Diagnostic Evaluation Records
Treatment Plan
Progress Notes
I understand that other laws about sharing of mental health, HIV/AIDS, genetic, and alcohol/drug treatment information may apply. I understand & agree that this information will be disclosed if I place my initials in the applicable space below:
Initial for Mental Health Information
Initial for Genetic Testing Information
Initial for HIVAIDS Information
Initial for DrugAlcohol diagnosis treatment or referral Information
I understand that I am not required to sign this authorization. | may revoke this authorization in writing at any time. If I revoke this authorization, the information described may no longer be used or disclosed for the purposes described here. If Northwest ADHD Treatment Center has already used or disclosed the information, that cannot be undone. | understand that the information used or disclosed as a result of this authorization may be subject to re-disclosure and no longer protected under federal law. However, I also understand that federal or state law may restric re-disclosure of HIV/AIDS, mental health information, genetic testing information, and drug/alcohol diagnosis, treatment or referral information. To revoke this authorization please send a written statement to the office manager at the address or fax number listed above and state that you are revoking this authorization. Unless revoked, this authorization expires 90 days after the completion of treatment. You can revoke this release by sending written notice to our office staff or your provider.
Patient Signature*

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Date*

MonthDayYear
Date
Parent Guardian Representative Signature

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Date

MonthDayYear
Date
Name of Parent Guardian Representative
ParentGuardian/ Representatives relationship to patient

Group Only Patient Consent and Practice Policies

This form is only to be completed by individuals referred by their mental health provider to Northwest ADHD Treatment Center for group participation only.
Confidentiality

Your personal health information is protected under the HIPAA act. Information about HIPAA is posted in the clinic and on our website. We are committed to safeguarding any information about your care including appointment, clinical, and billing information. We do not release any information without your written consent with the exception of the following:

If we believe you may be in danger of harming yourself or another person.
If there is reasonable cause to believe abuse or neglect of a child, elder, or someone with disabilities has occurred.
If a court order is received.
If required for insurance billing purposes, when you have given permission to bill that insurance for services.
When an emergency situation requires sharing of information.
Other situations required by law.

Group Treatment and Privacy

Group treatment cannot ensure confidentiality. All group participants must agree to respect the privacy of other group attendees. Group attendees must agree to not disclose what other group members said in group to anyone outside of group.

As an individual interested in group treatment, you may need to be contacted regarding group enrollment, scheduling, home exercises, or for other reasons related to your group engagement. By expressing interest in group treatment, you agree to be contacted by Northwest ADHD Treatment Center regarding the group. As all group members may need to be contacted, limited personal information - specifically your name and/or e-mail address may be shared with other potential or current group treatment participants.

Required Contact With Your Mental Health Provider

Please also be aware that in order to participate in group treatment at Northwest ADHD Treatment Center, we require that a valid release of information is on file with your referring mental health provider outside of Northwest ADHD Treatment Center. Our group providers will consult with your referring provider as needed to support your care. Northwest ADHD Treatment providers will not withhold information from your referring provider.

Team Approach to Care

Your Northwest ADHD Treatment Center group treatment providers (therapist and prescriber) may consult with other Northwest ADHD Treatment Center providers, as well as your referring provider, from time‐to‐time regarding your care.

Additionally, your case may be discussed in a confidential, multidisciplinary meeting of Northwest ADHD clinicians to facilitate treatment planning.

Northwest ADHD utilizes psychologist residents and other pre‐license providers in the practice who have completed their graduate education and are working to gain hours toward licensure. As such, pre‐license providers will communicate Protected Health Information (e.g. including name, age, occupation, etc.) to their on‐staff licensed supervisors and peer consults. All pre‐license providers will inform the patient or guardian who their licensed supervisor is in the intake session.

Confidentiality & Treatment of Children & Adolescents

In Oregon, minors aged 14 and older can legally obtain mental health treatment without parental consent. Per the law, the provider must include the parents before treatment is ended unless it is believed that to do so would cause harm. Treatment records may be reviewed by the parent or guardian. The clinicians of Northwest ADHD Treatment Center feel that the confidentiality of patients is necessary to ensure honest and open communication and will be maintained except in rare instances. Those instances include the exceptions above and communication with the parents or guardian for treatment planning.

Health Insurance Portability & Accountability Act (HIPAA)

Our practice, including our physical offices, remote offices, electronic records, telehealth services, and communications are HIPAA compliant. With this policy you have been given opportunity to review and keep a copy of our HIPAA Privacy Notice (Notice is posted in the waiting room at every office and on our website, nw‐adhd.com). Signing this notice indicates you have received, read, understood, and had the opportunity to ask us any questions about this policy. Signing also provides consent for Northwest ADHD Treatment Center to use and disclose your protected health information for the purposes of treatment, payment, continuity of care, and health care operations.

Appointments

Visits at Northwest ADHD Treatment Center are made by appointment only (no walk‐in hours).

You must be physically present in the state of Oregon for a telehealth appointment with your provider.

Regular participation in group is essential to benefit your treatment. Repeated missed group appointments may result in your withdrawal from the group.

It is the policy of Northwest ADHD Treatment Center that if you are not going to be able to attend your scheduled group appointment, please call our office to cancel at least 48 hours in advance of the scheduled appointment.

Appointments are the responsibility of the patient. Our automated appointment reminder service is a courtesy, please do not rely on it alone.

Arriving more than ten minutes after your scheduled appointment may result in the appointment being canceled, and the appointment will be recorded as a late cancellation. Having the full time allotted is necessary for your provider to give you adequate care. In the event that your provider is more than ten minutes late to see you, please know that they will make up the time with you to ensure the length of your appointment is not decreased.

If you would like to opt‐out or change your appointment reminders, you may update the front desk staff at any time.

If missed appointments become a regular occurrence, we will assume you are not ready for treatment at this time, and will terminate services with you.

We cannot perform evaluations for legal or custody issues and do not make it our practice to provide legal testimony.

If your phone number, address, or insurance has changed please update the front office staff before your appointment. You can also call our billing office to update your insurance information and ensure your provider(s) are in network with your new insurance company. Their phone number is 971-247‐9356.

Referrals to Other Northwest ADHD Treatment Center Services

You are being referred to engage in group treatment only at Northwest ADHD Treatment Center. Northwest ADHD Treatment Center does provide other services, including ADHD evaluation, psychological testing, individual psychotherapy, medication evaluation, and medication management. If you are interested in pursuing other services at Northwest ADHD Treatment Center, your referring provider must submit a separate referral form for non-group services. Please be aware that other services are in high demand, and there may be a significant waitlist prior to being able to access those services.

Telephone Calls

Our office can be reached during regular business hours. Please only contact Northwest ADHD Treatment Center at our published numbers. Providers working remotely may make calls from blocked numbers. Please ensure your phone is able to accept calls from blocked numbers, and is able to receive voicemails, so your provider can reach you. Typically, non‐urgent calls will be returned within two business days.

Typically, you will not be charged for a brief phone call with your provider. However, calls over 15 minutes will be considered a telephone appointment and will be billed to your insurance provider. You may be responsible for a copay, deductible, or any uncovered fees.

Emergency/ Urgent Services

Your referring provider is responsible for managing any urgent needs regarding your mental health. Please contact your referring provider or reference the plan that they have made with you about how to manage a mental health crisis.

In the case of a mental health emergency, you may call or text the national mental health crisis line at 9‐8‐8. You may also call 911 or go to the nearest emergency department. In the event of a crisis you may also contact:

Multnomah County Crisis Line: 503‐988‐4888

Clackamas County Crisis Line: 503‐655‐8401

Clark County Crisis Line: 503‐696‐9560

Washington County Crisis Line: 503‐291‐9111

Marion County Crisis Line: 503‐585‐4949

Poison Control: 503‐494‐8968 or 800‐452‐7165

Alcohol and Drug Help Line: 503‐244‐1312 or 1‐800‐923‐HELP

Portland Women’s Crisis Line (Domestic Violence): 503‐235‐5533

Rape Crisis Center: 503‐640‐5311

Cascadia Urgent Walk‐in Clinic at 2415 SE 43rd Ave 7am‐10:30pm

Text message‐based crisis service: accessible by texting to 741741.

If you are hospitalized, please inform hospital staff who your referring mental health provider is, so care can be coordinated before you are discharged.

Electronic Use Policy

Northwest ADHD Treatment Center utilizes an Electronic Health Record (EHR) and third‐party billing software, which meet compliance with HIPAA regulations. Additionally, diagnostic measures, appointment information, and account information are made available through our secure patient portal system. We may send electronic statements, appointment reminders, and payment receipts directly to your personal email. If you would like to opt out of e‐statements, please alert the front desk and a paper statement will be mailed to you.

It is the policy of Northwest ADHD Treatment Center to avoid using e‐mail and to primarily communicate with patients via phone to protect patient privacy. Confidentiality and privacy of email communication cannot be guaranteed. If a client does email a provider, it is assumed they understand the risk of disclosing Protected Health Information on non‐secure (i.e., unencrypted) media. EMERGENT AND/OR CLINICAL INFORMATION SHOULD NEVER BE EMAILED TO PROVIDERS. Providers cannot respond to emergencies (e.g. threat of suicide, prescriptions running out, etc.) in a timely manner using email.

Providers are prohibited from communicating with patients via any form of social media. Please be advised that if you opt to make an online review at sites such as Yelp, Google, Health Grades, etc. you may be compromising your own confidentiality through publicly identifying yourself as a patient. We do not reply to comments to protect your privacy.

We are always striving to improve the patient experience. If you would like to give feedback about your care, we recommend you speak with our operations manager or complete our patient feedback form.

Please let our staff know if you do not authorize voicemail messages left on your phone.

Please let our staff know if you do not authorize emailed billing statements.

Mutual Respect Policy

It is the expectation of Northwest ADHD Treatment Center that all individuals seeking treatment, providers, and staff regard one another with respect.

This includes being respectful of one another’s time and communicating appropriately. Northwest ADHD Treatment Center does not tolerate aggressive, intimidating, abusive, or controlling behavior. If you have concerns about your treatment by providers or staff, please inform our operations manager to ensure your concerns are addressed. Northwest ADHD Treatment Center reserves the right to suspend treatment and provide external referrals to anyone who exhibits threatening, intimidating, abusive, or otherwise inappropriate behavior toward staff, providers, or others.

Feedback Procedures

If you have feedback or concerns about your treatment, we encourage you to discuss this with your provider so they can resolve the issue. Northwest ADHD Treatment Center also has a feedback procedure. The patient feedback form is available upon request at the front desk, or on our website, and is reviewed by our operations manager and clinic owners. In the event this is not satisfactory, you may also speak to your insurance company or contact the board of your provider.

Termination of Treatment

You and your provider will regularly evaluate your need for group services over the course of your treatment. As you make and sustain progress in group treatment, your provider will develop a plan for the end of care with you.

There are additional circumstances which may result in an end to care:

If you provide no notice and do not attend three consecutive group appointments.

If you are not making regular efforts to engage with care, or miss appointments frequently.

If you engage behavior that is in any way abusive to your provider or staff of this office, or misuse or abuse medication or other substances.

If your provider identifies a conflict of interest, or that they are unable to meet your clinical needs.

If your treatment is terminated for any reason and you wish to re‐engage in treatment at Northwest ADHD Treatment Center, we will discuss your options at that time, which may include referral to an outside agency.

Court Testimony

Please be aware and understand that Northwest ADHD Treatment Center and our clinicians do not wish to be involved in legal proceedings with current or former patients, or their parents. By entering into treatment with us, you are agreeing to not name us as a party in legal/court proceedings or attempt to obtain records for legal/court proceedings for civil, custody, or divorce. If you are involved in, or anticipate being involved in, legal or court proceedings, please notify us as soon as possible. Also, entering treatment for therapy is not the same as a forensic or custody evaluation. If you need such an evaluation, we are willing to assist you in finding a provider who offers this service.

If we are subpoenaed, we will make every attempt to protect your confidentiality, but as outlined in the Practice Policy Statement, be advised there may be limitations. Your mental health record will become publicly available if used in a legal proceeding. We strongly recommend you speak with your provider about the potential risks if you elect to use your mental health records for legal proceedings. Please note, when allowed, we will charge for our testimony, including travel time, wait time, copies of records, and preparation/consultation time. We will charge the current legal rate as well as expenses incurred in copying and sending records. You will be responsible for these fees as health insurance companies will not pay for this.
Acknowledgement of Group Only Practice Policies
I have received, read, understood, and agreed to the practice policies as outlined in the Practice Policy Statement. I freely and voluntarily consent to treatment provided by Northwest ADHD Treatment Center. I understand I have the right to terminate my treatment at any time, and voluntarily consent to group treatment provided by Northwest ADHD Treatment Center. I understand I have the right to terminate my participation at any time.*
Please initial to indicate you agree to the above.
I understand that by expressing interest in group treatment, I consent to sharing limited personal information - my name and/ or e-mail address - with other potential group members and individuals in any group at Northwest ADHD Treatment Center I attend. I understand that while confidentiality is not possible in group treatment, that there is an expectation of privacy and all group members are required to not disclose any identifiable information about other group members learned over the course of group participation.*
Please initial to indicate you agree to the above.
I understand that a practice privacy policy is posted and available for my review in the front office and on the clinic website. I can request a printed copy at any time for my personal records.*
Please initial to indicate you agree to the above.
I understand that appointments must be canceled or rescheduled 48 hours in advance. If an appointment is canceled with less than 48 hours notice, it will be considered a late cancellation or no show. I am aware multiple late cancellations or no showing appointments can result in termination of my participation in group treatment at Northwest ADHD Treatment Center.*
Please initial to indicate you agree to the above.
I understand that my copay, coinsurance, deductible, or other fees are due at the time of service, and that I am responsible for all charges not covered by my insurance company.*
Please initial to indicate you agree to the above.
I understand that threatening, intimidating, abusive, aggressive, controlling, or inappropriate behavior will result in termination of my treatment at Northwest ADHD Treatment Center. I agree not to bring weapons on premises.*
Please initial to indicate you agree to the above.
I understand that beginning group services with Northwest ADHD Treatment Center is not a means to access other Northwest ADHD Treatment Center Services, including evaluation, ongoing therapy, or medication management services.*
Please initial to indicate you agree to the above.
Authorization to Release Information & Assignment of Insurance Benefits

Northwest ADHD Treatment Center has my permission to communicate with my insurance company in order to obtain authorization for services, provision of services, and coordination of care. Northwest ADHD Treatment Center has my permission to bill my insurance company, to exchange information, to obtain benefits and payment, and accept payments from the company on my behalf for all services relating to my care. I understand the cost of professional services rendered are charged to me and insurance billing is a courtesy. I understand that the billing department at Northwest ADHD Treatment Center attempts to obtain the most accurate information about my insurance benefits, however, I am ultimately responsible for understanding my policy. I authorize Northwest ADHD Treatment Center to bill my insurance company, and I understand I am financially responsible for all charges not covered by my insurance plan. I understand any monies credited as overpayment due to me will be refunded as soon as possible.

I attest that I have read, understood, and agree to all of the above.
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Parent/ Guardian Name
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Parent/ Guardian Signature (Only complete if applicable)

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NORTHWEST ADHD TREATMENT CENTER

Patient Information:

Patient Insurance Information:

By signing below, I acknowledge that I have read all of the information above. I am submitting this interest form for myself, or with the appropriate authority to submit this form on behalf of someone else.

Release of Information For Group Therapy Referral: Coordination of Care With Outside Behavioral Health Provider

INFORMATION WHICH MAY BE USED/ DISCLOSED:

Group Only Patient Consent and Practice Policies

Acknowledgement of Group Only Practice Policies