Serenium Wellness Patient Intake

Serenium

Intake Form
Intake Form
Serenium

TMS Intake Form
Please have your ID ready
Name of Client*

First NameMiddle NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Date
MaleFemaleNon-binaryPrefer not to say
Pronouns
Social Security Number
This field is optional
Email*
example@example.com
Mobile Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
E164
Error: incorrect phone number. Enter your 10-digit US phone number without the leading 1 country code (example: (609) 567-0980).*
Please upload a photo ID(Drivers ID or Proof of residence)

Cancelof
Age
Today

MonthDayYear
Date
HubSpot UTK
input_from
HubSpot Record ID

Address

Street Address

Street Address Line 2

City

Zip Code
State*
Which one of our locations would you like to be a patient of?*
YesNo
YesNo
See a map of all our locations
Emergency Contact Information
DISCLAIMER! Must be someone other than yourself.
Please fill in the full name of the emergency contact*

First NameLast Name
Please fill in the emergency contact phone number*
Please enter a valid phone number.Format: (000) 000-0000.

Insurance Responsibility
Please have your insurance card ready
Policy Information
Primary Insurance Company
Member ID
Please write your Insurance Company
Please upload the front and back of your primary insurance ID

Cancelof

Policy Holder / Legal Guardian
Policy Holder
Name

First NameMiddle NameLast Name
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
YesNo
Policy Information
Secondary Insurance Company
Member ID
Please write your Insurance Company
Please upload the front and back of your secondary insurance ID

Cancelof
Policy Holder / Legal Guardian
Policy Holder
Name

First NameMiddle NameLast Name
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State

I understand that having health insurance is not a guarantee that my condition is covered, and that insurance payment will be made.I authorize payment by my third-party payor (Insurance Company, Medicare/Medicaid, County, or other) or Credit Card to be paid directly to Premier Mental and Behavioral Services for services rendered.I understand that I am financially responsible to Premier Mental and Behavioral Services for charges applied to services provided, deductibles, co-pays, no- shows, and for all charges limited by my third-party payor.I understand that my insurance may cover only ONE (1) visit to specialist per day. If, for any reason, I will schedule two or more appointments (including other medical practices), I will be responsible for the charges that may not be covered by my insurance.I acknowledge that there may be payment processing fee associated with my payments to Premier Mental and Behavioral Services and that I will be responsible for covering these payment processing fees in addition to the aforementioned amounts.
I authorize Premier Mental and Behavioral Services to release information to the insurance companies provided on this form to submit insurance claims on my behalf. This authorization extends to the extent necessary to obtain payment for the services provided to me and includes authorization to release information about mental health, substance use, or HIV diagnoses as required.In consideration of the services provided to me, I assign all benefits to Premier Mental and Behavioral Services if accepted, and authorize my insurance companies, Medicare, or other third-party payers to make payments directly to Premier Mental and Behavioral Services and its affiliates. I understand that I remain responsible for all amounts due by me, including (but not limited to) copays, coinsurance, deductible amounts, and all services not covered by my insurance plan (including those for which I fail to obtain prior authorization), and mutually agreed-upon services or fees that are deemed not medically necessary.

Release of Information
I understand that no treatment, payment, enrollment, or eligibility for benefits may be conditioned on whether I sign this authorization. The facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.The information used or disclosed pursuant to the authorization may be subject to disclosure by the recipient and no longer protected by federal law, except for drug and alcohol treatment information.

I understand that I am entitled to a copy of this authorization
Relationship to Patient
YesNo
I hereby authorize the following designated office or person of to release or request the following personal information about my medical/psychiatric diagnoses, treatments, medications and lab results:
Request verbal report(s) from:
Request written report(s) from:
Release verbal information to:
Release written information to:
This authorization can be terminated at any time in writing. This authorization is valid for the duration of involvement, up to one year.

- We do not discriminate with regards to clients served on the basis of race, gender, ethnicity, socioeconomic status, or medical status.
  
  We hope that we can give you the kind of support and help that you are looking for. When you receive services from you have the right to:
  - The right to be free from unnecessary or excessive medication (see State Regulations)
  - The right to not be subjected to non-standard treatment or procedures, experimental procedures or research, or provider demonstration programs, without written informed consent.
    
    If the client has been adjudicated incompetent, authorization for such procedures may be obtained only pursuant to the requirements of State Regulations.
  - The right to treatment in the least restrictive setting, free from physical restraints and isolation.
  - The right to be free from corporal punishment.
  - The right to privacy and dignity.
  - The right to the least restrictive conditions necessary to achieve the goals of treatment/services.
  - Request a change of staff member if there is another staff person available who can address your issues and your request is reasonable -- you should know that discriminatory requests will not be considered
  This is what we ask from you: Client Responsibilities
  ▪ To cooperate with the to the best of your ability
  ▪ To attend scheduled appointments with your Case worker as agreed, in order to monitor your progress toward your outlined goals.
  ▪ To treat peers and professionals with the same dignity and respect with which you would like to be treated, with courtesy and respect
  ▪ To let know 24 hours before if you cannot come to an appointment.
- YesNo
- Refuse to acknowledge
  (Please write your full name)
- You may appeal staff or agency decisions and actions.
  1. Your Premier Mental and Behavioral Services case worker should be approached with the problem. If you and your case worker cannot reach a solution that is satisfactory, you should take the issue to the Administrator. If that step does not resolve the problem, you may go to the Executive Director of Premier Mental and Behavioral Services.
  2. If the complaint has still not been resolved to the client's satisfaction, the client may request review by the County Mental Health Board.
  3. If you are not satisfied with the recommendations of the County Mental Health Board, or the Agency's response to these recommendations, the client may request review by the Division of Mental Health.
  4. You can contact the External Advocacy Services at any time.
  5. The External Advocacy Services information is posted at the waiting area and is available at the front desk upon your request.
  
  You can contact the external advocacy services at any time:
  
  1. Community Mental Health Law Project
  
  Central Jersey: 225 East State Street, Suite 5, Trenton, NJ 08608
  Phone: (609) 392-5553, Fax/TTY: (609) 392-5369, E-mail: Trenton@chlp.org Managing Attorney: Stuart Weiner, Supervising Advocate: Jacqueline Darby;
  
  2. County Mental Health Administrator in the county
  
  Penny Grande, Administrator
  Middlesex County Division of Addictions & Mental Health Planning 75 Bayard St., New Brunswick, NJ 08901
  (732) 745-4313, e-mail: penny.grande@co.middlesex.nj.us;
  
  3. Division of Mental Health Services Ombudsperson
  
  Margaret Molnar
  PO Box 700. Trenton, NJ 08625, 609-984-4813
  
  4. Division of Mental Health Advocacy
  
  Justice Hughes Complex, 25 Market Street, Trenton, New Jersey 08625 (877)285-2844
  
  5. Division of Youth and Family Services (for child abuse and/or neglect)
  
  84 Park Avenue, Flemington, NJ 08822, (908) 782-8784
  
  6. County Welfare Agency (for Adult abuse)
  
  Monmouth County Board of Social Services 3000 Kozloski Rd, Freehold, NJ 07728 (732) 431-6000
- I have read and agreed the Grievance ProcedureI consent to receive Services for myself, or the individual identified above. My signature below demonstrates that I have reviewed the information as outlined above.
- No retaliation will be taken against you for filing this complaint or proceeding with the grievance procedure.
  Any patient who presents a grievance is to complete or be given assistance to complete this form. Once completed, the form is to be forwarded to Administrator. As per the Policy and Procedure Manual, the official grievance procedure is to be followed.

- I UNDERSTAND AND AGREE TO THE FOLLOWING:
  This Medication Management Agreement relates to my use of any and all medication(s) (i.e., benzodiazepines: Xanax, Diazepam, Clonazepam etc., Buprenex: Suboxone, Subutex; amphetamines: Adderall, Focalin, Concerta, etc, or other FDA approved psychotropic medications).
  There are federal and state laws, regulations and policies regarding the use and prescribing of controlled substance(s).
  
  Therefore, medication(s) will only be provided so long as I follow the rules specified in this Agreement.
  
  Physician may at any time choose to discontinue the medication(s). Failure to comply with any of the following guidelines and/or conditions may cause discontinuation of medication(s) and/or my discharge from care and treatment. Discharge may be immediate for any criminal behavior:
  - My progress will be periodically reviewed and, if the medication(s) are not improving my quality of life, the medication(s) may be discontinued.
  - I will disclose to Physician all medication(s) that I take at any time, prescribed by any physician.
  - I will use the medication(s) exactly as directed by Physician.
  - I agree not to share, sell or otherwise permit others, including my family and friends, to have access to these medications.
  - I will not allow or assist in the misuse/diversion of my medication; nor will I give or sell them to anyone else.
  - All medication(s) must be obtained at one pharmacy, where possible. Should the need arise to change pharmacies, Physician must be informed. I will use only one pharmacy and I will provide my pharmacist a copy of this agreement. I authorize Physician to release my medical records to my pharmacist as needed. I understand that my medication(s) may be eligible for refills on a regular basis. I understand that my prescription(s) and my medication(s) are exactly like money. If either are lost or stolen, they may NOT BE REPLACED.
  - Refill(s) will not be ordered before the scheduled refill date. However, early refill(s) are allowed when I am traveling and I make arrangements with Physician in advance of the planned departure date. Otherwise, I will not expect to receive additional medication(s) prior to the time of my next scheduled refill, even if my prescription(s) run out.
  - I will receive controlled substance medication(s) only from ONE physician unless it is for an emergency or the medication(s) that is being prescribed by another physician is approved by Physician. Information that I have been receiving medication(s) prescribed by other doctors that has not been approved by Physician may lead to a discontinuation of medication(s) and treatment.
  - If it appears to Physician that there are no demonstrable benefits to my daily function or quality of life from the medication(s), then Physician may try alternative medication(s) or may taper me off all medication(s). I will not hold Physician liable for problems caused by the discontinuance of medication(s). I will not hold Physician liable for problems caused by the discontinuance of medication(s). Urine drug screens are not supervised and there is no chain of custody.
  - I agree to submit to urine and/or blood screens to detect the use of non-prescribed and prescribed medication(s) at any time if you have a history, or we suspect you are under the influence of a substance. If I test positive for illegal substance(s), such as marijuana, speed, cocaine, etc., treatment may be changed to the more intense approach: detoxification, rehabilitation or referral to specialized program.
  - I agree that I shall inform any doctor who may treat me for any other problem(s) that I am enrolled in another medication management program, since the interaction with other medication(s) may cause harm.
  - I hereby give Physician permission to discuss all diagnostic and treatment details with my other physician(s) and pharmacist(s) regarding my use of medications prescribed by my other physician(s).
  - I must take the medication(s) as instructed by Physician. Any unauthorized increase in the dose of medication(s) may be viewed as a cause for discontinuation of the treatment.
  - I must keep all follow-up appointments as recommended by Physician or my treatment may be discontinued.
  - No guarantee or assurance has been made as to the results that may be obtained from my treatment. With full knowledge of the potential benefits and possible risks involved, I consent to treatment of my condition, since I realize that it provides me an opportunity to lead a more productive and active life.
  - I have reviewed the side effects of the medication(s) that may be used in the treatment of my condition. I fully understand the explanations regarding the benefits and the risks of these medication(s) and I agree to the use of these medication(s) in the treatment of my problem.
    
    By signing this agreement I confirm that the above written statements reviewed by me personally and that I will not hold my Physician liable for my conscious choice of not following these recommendations.
- Provides a wide range of services to adults, adolescents and children as well as to their families.
  Our Program is designed to help individuals, who do not require hospitalization, but can benefit from participation in a structured therapeutic environment. The program can function as a step- down program from partial hospitalization, detoxification, or residential services; may be used to prevent or minimize the need for a more intensive and restrictive level of treatment; and is considered to be more intensive and integrated than traditional outpatient services. This strategy addresses mental and emotional health needs and provides a supportive and caring environment.
  Our program helps clients understand the relationship between their thoughts and behaviors. Through education and group therapy individuals develop coping skills to improve their mental health and, thus, their daily lives.
- Patients will:
  - Recognize personal strengths and weaknesses
  - Develop essential coping skills
  - Identify, challenge and modify distorted thoughts and beliefs
  - Improve their ability to problem solve and cope with emotional crises
  - Work to change dysfunctional or destructive behavior patterns
  - Refine communication skills
  - Set immediate and long-term goals
  - Complete structured homework assignments
  - Build an effective aftercare plan
  The purpose is to promote positive emotional wellbeing in patients as well as to empower families to provide a nurturing and safe support for their significant others. The treatment is person centered, family focused, strength-based and culturally competent.
  - We are a community based agency that offers a continuum of quality outpatient behavioral health services:
  - Diagnostic Evaluation: Psychiatric Evaluations and psychological testing are available to children actively engaged in treatment.
  - Psychotherapy: The Agency provides individual, family, and group therapy to its clients.
  - Medication management: The Agency provides individual approach with psychopharmacology treatment options.
  Community-Based Services:
  - Agency outreaches school guidance counselors and school psychologists about an opportunity of psychotherapy services to children, adolescents and their families.
  - Agency provides up to date information to the local hospitals' social workers regarding after care opportunities for discharged patients.
  - Advocacy: Outpatient therapists advocate for families in order to help them overcome or confront barriers to better education, housing, health or other social/human needs. In order to increase access to care, therapists provide treatment.
- Screening procedure and intake
  
  Integrated Assessment
  - mental health symptoms
  - evaluation of co-occurring health conditions
  - psychosocial evaluation
  - functional impairments
  - evaluation of co-occurring substance abuse issues, that affect mental health problems
  Service planning
  - Psychoeducation and Illness Self-Management
  - Family Support
  - Treatment for Co-Occurring Conditions
  - Peer Support
  - Psychiatric and psychotherapy Care
  - After care planning
- Initial Assessment: Your first appointment will be what is commonly called the “Intake Session.” This is an individual session with the Intake Specialist who will determine your mental health needs and desires. Information collected during this interview includes: Demographics, mental health history, medical history, social history, substance abuse history, legal history, occupational history, mental status, etc. You will be asked a number of questions and fill out forms designed to assess your current and past physical and emotional health. Every effort will be made to coordinate your services with your primary care physician and/or other current or past treatment entities upon your signed consent. This information is necessary to provide you with the most effective treatment regimen, an initial diagnosis and assignment to the appropriate therapist for ongoing treatment. Together you will also design an initial treatment plan. The treatment plan will address your concerns and assist you in working towards the goals that you feel are most important to your well-being. This information will give you the opportunity to ask further questions about your treatment and will provide the assigned treating therapist with a deeper understanding of your situation; assess whether the individual has other needs that might be better met by alternative treatment or providers.
  
  Psychological Evaluation: When a psychological screening does not provide conclusive information about an individual's problems, psychological testing is recommended to get a more complete understanding of the individual in order to facilitate treatment planning.
  
  Psychotherapy (counseling): During psychotherapy/ counseling you will explore a wide range of emotional problems and life stressors. You will learn and gain insight concerning your condition, mood, feelings, relationships, thoughts and behaviors. You will work together with your therapist to find new ways of coping, problem solving, and resolution of the issues which have led to your current life difficulties. If it is determined that you might benefit from medication, you will be referred to one of 's psychiatrists or your primary care physician or other medical provider of your choosing. You may be asked to do “homework” or other activities which might be of benefit to you as a part of the treatment process. When appropriate, you will be asked to help develop and adhere to a detailed emergency crisis plan. You are free to ask questions of your therapist at any time and to request a change of therapists if you feel you are not making sufficient progress.
  Individual/Family/Couples Therapy: Individual/Family/Couples Therapy is for those individuals who demonstrate a need for psychotherapy during the psychological screening. The therapist, with client input, will determine the form of psychotherapy that would best serve the client's needs. The client is seen individually if problems are primarily associated with his/her functioning or if family/significant others are unwilling to attend therapy. If problems are embedded within the couple's dyad or family system, those therapies are provided.
  
  Time Frames: Treatment sessions generally are between 30 and 60 minutes. The frequency of appointments is determined between you and your therapist. How long you need to be in therapy depends upon your situation. This can be as short as a few weeks or up to a year or more depending upon severity. Of course, unless you are under court commitment, other court order or a minor, you are free to self-discharge at any time of your choosing. However, if you are on medication it is strongly recommended you inform your medical care provider of such action.
  
  This portion is intended to inform you that the person who will be providing counseling services and case management to you may be a Licensed Associate Counselor (LAC) in the state of New Jersey.
  
  A Licensed Associate Counselor is an individual who:
  -has obtained a master’s degree or doctorate degree in counseling from a regionally accredited institution of higher education.
  -has passed the National Counselor Examination administered by the National Board of Certified Counselors indicating that the individual meets the national standards.
  -is legally able to provide counseling, counseling interventions, appraisal and assessment, consulting, referral and research activities only under the direct supervision of a qualified supervisor.
  
  A “qualified supervisor” for an LAC is an individual who:
  -has been fully licensed to provide mental health counseling services for a minimum of 2 years.
  -has at least 3,000 hours of clinical work experience in New Jersey in the last 6 years
  -has obtained the Approved Clinical Supervisor (ACS) credential from the National Board for Certified Counselors Center for Credentialing and Education or has completed at minimum 3 graduate credits in clinical supervision from a regionally accredited institution of higher education.
  
  A "licensed social worker" is an individual who has:
  - Received a master's degree in social work from an educational program accredited, or in candidacy for accreditation, by the Council on Social Work Education or a doctorate in social work from an accredited institution of higher education; and
  - Passed an appropriate examination provided by the board for this purpose.
  - The board shall certify an applicant who has received a baccalaureate degree in social work from an educational program accredited, or in candidacy for accreditation, by the Council on Social Work Education
  
  Clinical supervision for an LSW shall be rendered by an LCSW who:
  - Has been licensed as an LCSW for a minimum of three years
  - Has completed at least 20 continuing education credits of post-graduate coursework related to clinical supervision approved by the State Board of Social Work Examiners
  
  If you have questions about your treatment, please speak to your counselor or their supervisor. By signing this document I am showing I understand the person in charge of my primary care may be a Licensed Associate Counselor who is practicing under the supervision of the qualified supervisor listed above and not practicing independently, I am giving my consent to be treated by this individual, an I am giving my consent for the LAC named above to disclose Protected Health Information to the qualified supervisor as needed to support and inform the supervision process.
- Tele behavioral health is the delivery of psychiatric evaluation and medication monitoring as well as psychotherapeutic services using interactive audio and visual systems where the psychiatrist or therapist are not in the same physical location.
  
  The interactive electronic systems used in telebehavioral health incorporate network and software security protocols to protect the confidentiality of patient information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.
- My Rights
  
  I understand that:
  - the laws to protect the privacy and confidentiality of medical information also apply to telebehavioral health;
  - the telebehavioral health platform used by Premier Mental and Behavioral Services is encrypted to prevent the unauthorized access to my private medical information;
  - the Premier Mental and Behavioral Services provider has the right to withhold or withdraw his/her consent for the use of telebehavioral health during the course of my care at any time;
  - all the rules and regulations which apply to the practice of medicine, social work and professional counseling in the state of New Jersey also apply to telebehavioral health.
  - I have the right to withhold my consent to the use of telebehavioral health during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment.
- My Responsibilities
  - I will not record any telebehavioral health sessions without written consent from the Premier Mental and Behavioral Services provider. I understand that all Premier Mental and Behavioral Services providers will not record any of our telebehavioral health sessions without my written consent.
  - I will inform a Premier Mental and Behavioral Services provider is any other person can hear or see any part of our session before the sessions begins.
  - The Premier Mental and Behavioral Services provider will inform me if any other person can hear or see any part of our session before the session begins.
  - I understand that I must take reasonable steps to protect myself from unauthorized use of my electronic communications by others.
  - Understand that I, not the Premier Mental and Behavioral Services provider, am responsible for the configuration of any electronic equipment used on my computer which is used for telebehavioral health if I am at a location other than the Premier Mental and Behavioral Services videoconferencing area.
  - I understand that I must be a resident of, and physically located in New Jersey to be eligible for Telebehavioral services Premier Mental and Behavioral Services.
  - I agree that I have verified to Premier Mental and Behavioral Services my identity and current location in connection with the telehealth services. I acknowledge that failure to comply with these procedures may terminate the telehealth visit.
  - I understand that I have a responsibility to verify the identity and credentials of the
    healthcare provider rendering my care via telehealth and to confirm that he or she is
    my healthcare provider.
- I understand that:
  - Telehealth involves the communication of my medical/mental health information in an electronic or technology-assisted format
  - It is my responsibility to ensure the proper functioning of all electronic equipment before the session begins;
  - I must be a resident of, and physically located in New Jersey to be eligible for telebehavioral health services from Premier Mental and Behavioral Services;
  - Telehealth billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), Medicare, or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage.
  - some of my appointments may not be done by telebehavioral health. I will be notified of which, if any appointments need to be done face to face;
    the provider (MD/APN/PA/Clinician) may ask me to verify my identity to the satisfaction of the provider before the session begins;
  - I will be responsible to pay any co-pays, co-insurances and insurance deductible owed to Premier Mental and Behavioral Services through pre-arranged methods at the time of each session;
  - I may be charged if I do not show up for my scheduled appointment or if I cancel my appointment within less than 24 hours;
  - telebehavioral health at with Premier Mental and Behavioral Services may take one of three (3) forms:
    
    Patient is at the Premier Mental and Behavioral Services office and the provider (MD/APN/PA/clinician) is remote (not at from Premier Mental and Behavioral Services);
    
    Patient is remote and the provider is at from Premier Mental and Behavioral Services;
    
    Both the patient and the provider are remote.
  - Any prescriptions that I need will be sent directly to my pharmacy via electronic transmission.
  - All electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to:
    
    It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures.
    
    Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network.
    
    Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures.
  - Information exchanged during my telehealth visit will be maintained by the doctors, other healthcare providers, and healthcare facilities involved in my care
  - Medical information, including medical records, are governed by federal and state laws that apply to telehealth. This includes my right to access my own medical records (and copies of medical records).
  - Skype, FaceTime, or a similar service may not provide a secure HIPAA-compliant platform, but I willingly and knowingly wish to proceed.
  - Premier Mental and Behavioral Services is not responsible for breaches of confidentiality caused by an independent third party or by me.
  - Electronic communication cannot be used for emergencies or timesensitive matters.
  - A medical evaluation via telehealth may limit my healthcare provider’s ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider’s recommendations—including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit.
  - Electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc.).
  - My healthcare provider may choose to forward my information to an authorized third party. Therefore, I have informed the healthcare provider of any information I do not wish to be transmitted through electronic communications.
  - The inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit.
  - There is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided.
  - I agree to waive and release my healthcare provider and Premier Mental and Behavioral Services from any claims I may have about the telehealth visit
  - Electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community.
- I*
  Full Name
- I have read and understand the information provided above regarding telebehavioral health, and have discussed it with a Premier Mental and Behavioral Services staff member and all of my questions have been answered.I hereby give my consent for the use of telebehavioral health in my psychiatric care and authorize Premier Mental and Behavioral Services to use telebehavioral health in the course of my treatment.
- I have read and agreed to all of the above.

OFFICE POLICIES

Please read and sign
Appointment Cancelation Policy
As a patient of Premier Mental and Behavioral Services, it's important to be aware of the following policy:
- If I cancel my appointment with less than 24 hours notice, it will be considered a no show.
- If I reschedule my appointment with less than 24 hours notice, it will be considered a last minute reschedule.
- If I have 3 no shows or last minute reschedules within 90 days, all future appointments will be canceled.
- To continue my therapy treatment, I will need to pay both fees*. This will result in me being placed on the waitlist and my next appointment being scheduled based on availability.
- The fees will not be charged until I confirm my desire for continuing the treatment.
- No show or last minute reschedule records reset every 90 days.
- If I am seeing a specialist for medication management and I refuse to pay the fees mentioned above, I understand that I will be provided with one last refill of my medication and then my treatment will be automatically terminated.
* Fee rates are mentioned under "Other fees" in this document.
Initials *
I , Full Name* , authorized to charge my Credit Card for services provided, deductibles, co-pays, no- shows, and for all charges limited by my third-party payor.

Uninsured Self Pay Options:

Counseling/ Therapy (40 - 45 min):

Mental Health Comprehensive Assessment	$200.00
Follow Ups	$125.00
Group Counseling	$55.00
IOP:	$250.00 / 3hrs / day
Couples Intake	$200.00
Couples Follow Up	$125.00
Please call for Discounted Rates

Medication Management:

Psychiatric Intake	$300.00
Follow ups	$175.00
Please call for Discounted Rates
All rates are subject to change

Other Fees:

No Show Fee	$50.00
Last Minute Reschedule	$50.00
No Show Fee Meidcaid & Medicare	$50.00
Last Minute Reschedule Medicaid & Medicare	$50.00
Medical Records - $1.00 per page	$25.00 Minimum
Excuse From School Letter	FREE
Office Letter	$25.00
Counselor Letter	$75.00
Doctor / APN Letter	$100.00

- You may request copies of your chart notes and medical records to be sent to your current provider, you will be charged $1 per page for the physical copies. Additional processing fees may apply. For the requested reports or any letters or notes you will be charged $25.00 and up.
- In case of lost or stolen prescription of controlled substance medications, patients are advised to go to their local Emergency room, as these prescriptions WILL NOT be replaced.
- I understand that in the EVENT OF A MEDICAL EMERGENCY, I am to go to the nearest emergency room or call 911 to seek out proper help. I acknowledge that my doctor is not responsible for providing emergency treatment and practice, outpatient treatment only.
- The client will be charged $50 fee for any returned checks with insufficient funds.
- Refund Policy: Once service is rendered the payment is final.
AN IMPORTANT MESSAGE ABOUT INSURANCE COVERAGE

We file all insurance claims as a courtesy to our patients; however your insurance policy reflects a contract between you and your insurance company. It is your responsibility to be familiar with your carrier and pay any co-pay or deductible required by your policy at the time of your visit. You are responsible for any charges not covered by your insurance policy.

I understand that my eligibility for coverage by my insurance policy may not be confirmed at the time I wish to receive services from. If it is determined that I am not eligible for coverage, I understand that I will be responsible for payment of all services provided.
Signature*

Clear
Intake type
Leadsource
JoT Form Name
Clinic Part 1
By submitting my information, I agree to be contacted by Premier Mental and Behavioral Services via calls, emails and text messages. I understand that these communications may include updates and inquiries for further information, and that I can unsubscribe at any time.
utm_source
utm_medium
utm_campaign
Client Email
example@example.com
sourceUrl
Should be Empty:

Serenium

Intake Form

Serenium

Emergency Contact Information

Insurance Responsibility

Release of Information

OFFICE POLICIES