Returning Client Update

Changes for 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 be updated to 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, they (the client) will need to sign a set of Release of Information forms for each individual!**

Changes for Clients now 18+
Now that the client is over the age of 18, the client's existing account must be updated to reflect the CLIENT as the primary user (if not done already)!
- By default, only the CLIENT will be included on scheduling emails/have access to the account!
- If the client would like ANY parents/guardians to be included in the intake process and/or on the account, they must be included as Additional Users section (at the end of this form).
**If the client would like ANYONE other than themself to be included in the intake process and/or on the account, they (the client) will need to sign a set of Release of Information forms for each individual!**

Returning Client Update...
Provider Name:
Has the DATE/TIME of the new appointment already been identified?*

NoYes
Has the client's insurance information changed since the last services with Therapy Resources?*

NoYes
Has the billing information/financial responsibility changed since your last services with Therapy Resources?*

NoYes
Should anyone other than the client themself (as reported) be included in the intake process and/or have access to the Patient Portal account (i.e. parents/guardians, partners)?*

NoYes

Client Information
Contact information MUST be for the CLIENT* themself!

(*If the client is 13 years or younger, one parent's email address and phone number can be used for the client)
Client's Full Name*

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

MonthDayYear
Client's Sex*
Client's Pronouns
Client's Phone Number*
Client's Email Address*
Has the client's street address changed since the services with Therapy Resources?*

YesNo

If the new appointment has not been identified, please specify when the client is available to meet for weekly sessions (e.g. 9AM, 1PM, 7PM)

Indicate type of service preference:

Telehealth OnlyIn-Office OnlyHybrid / BothNo Preference
Note any potential scheduling conflicts:
Unless otherwise discussed with the Provider, sessions are typically held weekly.

Billing Information (If Applicable)
Please indicate who to contact for payment and other financial matters:

Client / SelfOther Representative / Responsible Party
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
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...
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:

Returning Appointment Request Form