Appointment Request Form

Clients 14yo through 17yo

For clients aged 14 through 17, federal and state confidentiality laws dictate that client consent is required for any parent/guardians to access certain types of medical information (such as drug & alcohol, mental health, reproductive health and certain diseases).
As such, the client's existing account must reflect the CLIENT as the primary user, and at least ONE parent/guardian as financial guarantor!
- Unless otherwise indicated, only the CLIENT will have access to the full set of required forms; the financial guarantor's access will be limited to billing/financial information!
- Multiple parents/guardians can be included in the intake process and/or on the account using the Additional Users section at the end of this form.
**If the client would like ANYONE other than themself (including the financial guarantor) to have FULL ACCESS to the account, the client themself will need to sign a set of Release of Information forms for each individual!**

Relational (Couple's & Marital) Services
Couple's/Marital Services are processed in the name of one partner (sometimes referred to as the "primary client")!
- By default, only the primary client will be included in scheduling emails and given access to the Patient Portal account, which contains all required clinical forms.
*OPTIONAL* If you would like any additional partner(s) to be included in the scheduling process and/or have access to your Patient Portal account, they must be added as Additional Users at the end of this form!
- If you choose to include any additional users in this request, the primary client will be required to complete and sign a set of (two) Release of Information forms for each additional user.
  *If these forms are not completed/received, the additional user will lose access to the account*

Client Information
Client's Full Name*

First NameLast Name
Preferred Name
Client's Date of Birth*

MonthDayYear
Client's Sex*
Client's Pronouns
Contact information MUST be for the CLIENT

If the client is 13 years or younger, one parent's email address and phone number can be used for the client
Client's Phone Number*
Client's Email Address*
Client's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Who will be financially responsible for services:*

Client (Must be 18yo+)Person submitting this form (not client)Other Representative / Responsible Party
Should anyone other than the client be included in the scheduling process?*

NoYes
Should anyone other than the client have access to the Patient Portal account (and the forms within)?*

NoYes

Billing Information

If the client is under the age of 18, a PARENT/GUARDIAN MUST be listed as financial guarantor!
Financial Guarantor's Name*

First NameLast Name
Financial Guarantor's Relationship to Client*

Parent / Legal GuardianSpouseOther
Financial Guarantor's Date of Birth*

MonthDayYear
Financial Guarantor's Gender
Financial Guarantor's Phone Number*
Please enter a valid phone number.
Financial Guarantor's Email*
example@example.com
Financial Guarantor's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Should the Financial Guarantor be included in the initial Scheduling process?*

NoYes
For clients aged 18 and older, the client will need to sign a set of Release of Information forms to include any other individual in the scheduling process!

If these forms are not completed and signed, we will not be able to discuss the intake/scheduling process with anyone other than the client themself.
Do you want the Financial Guarantor have access to the client's patient portal?*

NoYes, Financial Only (billing information only)Yes, Full Access (both financial and clinical information)
For clients aged 14 and older, the client will need to sign a set of Release of Information forms to allow any individual to have full access to the client's account.

If Release Forms are not received, access will be REMOVED or LIMITED to Financial Only.

To help ensure confidentiality and placement with an appropriate provider...
Has the client ever received mental health services with Therapy Resources of Morris County?*

NoYes, with...
Does the client know or have a personal relationship with any of our providers (e.g. friends, family, past or current colleagues, etc.)?*

NoYes, with...
Is the client being discharged or has the client recently been discharged from a higher level of care?*

YesNo
Are there/will there be any other parties (e.g. attorney, DCP&P, etc.) involved in these services?*

YesNo

Additional User #3

NOTE: The purpose of an Additional User is to assist with the completion of the required forms and/or have access to client financial information (if applicable). If Release of Information Forms are required, they will be sent via the Patient Portal.
Additional User #3's Name

First NameLast Name
Additional User #3's Relationship to Client

Parent/Legal GuardianPartner / SpouseOther
Should Additional User #3 be included in the Intake and Scheduling process?

YesNo
(3a) Should Additional User #3 have access to the Patient Portal account?

YesNo
(3b) What patient portal access should Additional User #3 have?

Financial Access only (limited to billing forms)Full Access
Additional User #3's Date of Birth

MonthDayYear
Date
Additional User #3's Gender
Additional User #3's Phone Number
Please enter a valid phone number.
Additional User #3's Email
example@example.com
To include more additional users to these services, please email our Intake Department at intake@therapyresourcesmc.com. Please include the requesting Client's name and Date of Birth to ensure the information is going to the correct client.

Submitter Signature*

Clear
By signing this form, you are submitting a request for services with Therapy Resources of Morris County. For questions, please contact our Intake Department at intake@therapyresourcesmc.com
Should be Empty:

Clients 14yo through 17yo