URBAN HEALTHY MINDS – CLIENT REGISTRATION, CONSENT & HIPAA FORM

URBAN HEALTHY MINDS – CLIENT REGISTRATION, CONSENT & HIPAA FORM

Address: 11500 S. Eastern Ave., Suite150, Henderson, NV 89052| Phone: (702) 661-7436| Fax: (702) 552-7138| Email: info@urbanhealthyminds.com| Website: www.urbanhealthyminds.org
Today's Date

MonthDayYear
Date
SECTION 1 — CLIENT INFORMATION
Name

First NameLast Name
Preferred Name

First NameLast Name
GENDER IDENTITY
Gender: Male/Female/Other: Nonbinary/Other
AGE:
DATE OF BIRTH (MM/DD/YYYY):
PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
EMAIL
example@example.com
PREFERRED LANGUAGE
English, Spanish, Other (Please Specify)
Interpreter Needed?
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SECTION 2 — DEMOGRAPHIC INFORMATION

Please include the following demographic information for our records: (Please select all that apply)

Rows	American Indian or Alaska Native	Asian	Black or African American	Native Hawaiian or Other Pacific Islander	White	Middle Eastern or North African	Other (Please specify)	Prefer not to answer
RACE

ETHNICITY

Rows	Hispanic or Latino	Not Hispanic or Latino	Prefer not to answer
ETHNICITY

VETERAN STATUS (Required for state & federal reporting)

Rows	Yes, I am a veteran.	No, I am not a veteran.	Prefer not to answer.
VETRAN STATUS

DISABILITY STATUS (Optional)

Rows	Yes, I identify as a person with a disability.	No, I do not identify as a person with a disability.	Prefer not to answer.
DISABILITY STATUS

If yes, what type of disability?

Rows	Physical disability	Intellectual or developmental disability	Sensory disability (hearing, vision)	Mental health condition	Chronic medical condition
DISABILITY TYPE

Other (Please specify)
SECTION 3 — PARENT/GUARDIAN INFORMATION (If Applicable)
Is the client a minor?
Parent/Guardian Information (If Applicable) Name of Parent/Guardian

First NameLast Name
Relationship to Client
Legal Guardian?
Upload Custody Documentation

Upload Only if “Legal Guardian = Yes”
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Parent/Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
SECTION 4 — EMERGENCY CONTACT
Emergency Contact Name

First NameLast Name
Emergency Contact Telephone Number
Relationship to Client
SECTION 5 — COMMUNICATION CONSENT
How may we contact you? (Select all that apply)
Appointment Communication Preferences:
Would you like to receive appointment reminders? If yes, please indicate Preferred method(s) of communication Please indicate all applicable methods: Text Message, Telephone Call, or Email
SECTION 6 — HEALTHCARE PROVIDERS

Primary Care Physician or Doctor's Care
Do you have a Primary Care Physician?    YES      NO
Physician's Name and phone number:
First Name   Last Name
Area Code Phone Number

Other Providers Involved in Care?
If yes, please list the following information for each provider:

Provider Name:   First Name   Last Name
Specialty:
Clinic Name:
Phone Number:   Area Code Phone Number

Are you currently taking prescribed medications?
Yes   No
If Yes → Please list medication (s) list:
Type a label   Type a label    Type a label
SECTION 7 — INSURANCE INFORMATION
Insurance Company & Member ID #
Group Number & Subscriber Name
Subscriber DOB & Relationship to Subscriber
SECTION 8 — CLINICAL HISTORY
Presenting Concern?
Please describe the main issues or problems that are currently causing you concern.
Have you had previous mental health treatment?
If yes, please describe previous treatment
Have you had any psychiatric hospitalizations?
If Yes, Dates & details
Substance Use History?
If Yes, Substances used & frequency
Current Stressors?
Strengths & Supports?
SECTION 9 — SAFETY SCREENING
History of suicidal thoughts?
History of self‑harm?
History of violence or aggression?
Current safety concerns?
If Yes, Describe current safety concerns
SECTION 11 — CONSENTS
A. Consent for Treatment
“I consent to receive behavioral health services from Urban Healthy Minds.”
Print Name
Signature of Client (or Parent/Guardian):
Date

MonthDayYear
Date
B. HIPAA Notice of Privacy Practices Acknowledgment

“I acknowledge that I have received and reviewed the Notice of Privacy Practices.”
By signing below, I confirm that I have carefully read and fully understand the information provided in this form. I give my consent to Urban Healthy Minds and its authorized representatives to use the information above for registration, care coordination, and essential communications related to my services. I understand that all personal information will be handled with strict confidentiality in accordance with applicable privacy laws.
Date

MonthDayYear
Date
C. Telehealth Consent

Telehealth Consent Acknowledgment
Telehealth services allow clients to receive behavioral health care through secure video or audio communication platforms. By participating in telehealth, you acknowledge and understand the following:

Risks and Benefits:
Telehealth offers increased access to care, reduced travel time, and greater scheduling flexibility. However, risks include potential data security breaches that could result in unauthorized disclosure of personal health information. Technical difficulties such as poor internet connectivity, audio or video disruptions, or software malfunctions may interrupt or delay the session. Telehealth also has limitations, including the inability to conduct a full physical examination or provide immediate in‑person interventions.

Technology Limitations:
Telehealth relies on technology that may not always function as expected. Limitations may include inadequate internet bandwidth for high‑quality video conferencing, outdated or incompatible software or hardware, and potential cybersecurity threats despite reasonable safeguards. Clients are responsible for ensuring they have access to a private, secure location and reliable technology for sessions.

Emergency Procedures:
Because telehealth sessions occur remotely, additional safety measures are required. Clients agree to provide an up‑to‑date emergency contact who may be reached if a safety concern arises during a session. Instructions on how to access local emergency services will be provided. A plan for transferring care or escalating to in‑person services will be implemented if necessary to ensure client safety.

By signing below, you acknowledge that you understand the risks, benefits, and limitations of telehealth services and voluntarily consent to participate. You may withdraw consent at any time without affecting your right to future care. All telehealth sessions will follow HIPAA privacy and confidentiality standards to the extent possible through electronic communication.
Telehealth Consent Acknowledgment
Parent/Guardian Telehealth Consent (If Client is a Minor) By signing below, I confirm that I am the parent or legal guardian of the minor client and I consent to their participation in telehealth services.
D. Financial Responsibility Agreement
By receiving services at Urban Healthy Minds, you acknowledge and agree to the following financial responsibilities:

Insurance Billing:
Urban Healthy Minds will bill your insurance company using the information you provide. You understand that insurance coverage is not a guarantee of payment and that you are responsible for providing accurate and up‑to‑date insurance information at all times. Any services not covered, denied, or applied to your deductible remain your financial responsibility.

Copays and Deductibles:
You agree to pay all required copays, coinsurance amounts, and deductible balances as determined by your insurance plan. These amounts are due at the time of service or upon notification from Urban Healthy Minds.

No‑Show and Cancellation Policy:
Missed appointments or cancellations made with less than 24 hours’ notice may result in a no‑show or late‑cancellation fee. These fees are not billable to insurance and are the client’s responsibility.

Credit Card on File Policy:
Urban Healthy Minds requires a valid credit or debit card to be kept on file for payment of copays, deductibles, no‑show fees, and any outstanding balances. By signing below, you authorize Urban Healthy Minds to charge your card for any patient‑responsibility amounts owed.

By signing below, you acknowledge that you have read, understand, and agree to the financial policies listed above
D. Financial Responsibility Agreement

Insurance billing - Copays & deductibles - No‑show/cancellation policy - Credit card on file policy
E. Coordination of Care Consent

I authorize Urban Healthy Minds to coordinate care with other providers as needed.
E. Coordination of Care Consent
G. Minor Treatment Consent (If applicable)
F. Minor Treatment Consent

ONLY IF CLIENT IS A MINOR
Please upload both the front and back of the client's insurance card.

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Please upload the front and back of the client's or parent/guardian's identification.

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Please upload here any additional documents or authorizations that are relevant to this registration process, including but not limited to, any specific forms, permissions, or legal papers that are required or helpful for Urban Healthy Minds to provide comprehensive and appropriate care.

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URBAN HEALTHY MINDS – CLIENT REGISTRATION, CONSENT & HIPAA FORM

SECTION 1 — CLIENT INFORMATION

SECTION 2 — DEMOGRAPHIC INFORMATION

SECTION 3 — PARENT/GUARDIAN INFORMATION (If Applicable)

SECTION 4 — EMERGENCY CONTACT

SECTION 5 — COMMUNICATION CONSENT

SECTION 6 — HEALTHCARE PROVIDERS

SECTION 7 — INSURANCE INFORMATION

SECTION 8 — CLINICAL HISTORY

SECTION 9 — SAFETY SCREENING

SECTION 11 — CONSENTS

A. Consent for Treatment

B. HIPAA Notice of Privacy Practices Acknowledgment

C. Telehealth Consent

D. Financial Responsibility Agreement

E. Coordination of Care Consent

G. Minor Treatment Consent (If applicable)