IMPACTGROUP INTAKE APPLICATION

PRESENTING PROBLEM(S)
Please Check ALL That Apply
Pregnant
If Yes, Due Date:
Compliance with Prenatal Care:
Doctor:
PAST TREATMENT
*Has the client been diagnosed with a behavioral or mental disorder in the past?
If "Yes" what diagnoses was given?
*Was the client prescribed any medication for the diagnosis?
If "yes" what medication(s) were prescribed?
*Has the client ever been enrolled in another agency/program?
If "yes" where?
*Were services completed?
REFERRAL SOURCE/INITIAL ASSESSMENT APPOINTMENT
Referral Source Name/Office:
Office Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Initial Assessment Appointment Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time

Hour Minutes

AM/PM Option
AUTHORIZATION FOR OUTPATIENT TREATMENT
I, type name*do hereby authorize Impact Group BHS it’s consultants, therapists, medical staff employees, and whomever else may be necessary to administer outpatient therapy and or procedures that are considered necessary for my treatment.

I understand that various procedures and treatments may be used, and that liability of Impact Group BHS and its employees are limited only to negligence.

The Services Provided Are As Follows:
____ Assessment ____ Group Counseling ____ Education ____ Family Counseling
____ Psychiatric Evaluation ____ Medication Management____ Home and Community Based ____Assertive Community Treatment____ Substance-IOP

I, furthermore, give Impact Group BHS Authorized Staff permission to provide Emergency Medical Treatment if needed.
Client's Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client's Signature / Parent/Guardian's signature if client is under 18
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
IGBHS Authorized Staff:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PATIENT SAFETY PLAN

When there is potential for dangerous behaviors, or a behavioral health crisis, a personal safety plan will be completed. The self-care plan may be used as a prevention plan to assist in the identification of triggers and warning signs of a serious regression. This plan will be developed within (insert timeframe, e.g., the day of admission, immediately when the potential for dangerous behaviors is identified or actual dangerous behaviors have occurred; or, within 24 hours of discharge from the program for persons served)

What are my triggers? Triggers are brief expressions that cause negative feelings and destructive reactions.

Sleep Problems Goal Interrupted Relationship Issue

School Stress Being Alone Travel

Argument Family Event ________________

Work conflict Social Conflict ________________

Romantic Problem Social Media Issue ________________

Overeating Yelling ________________

Hurting Self Test Taking ________________

Crowds Specific Person ________________

What are my early warning signs? These are revealed through changes in your thinking, behaviors, and emotions which are often a result of a trigger. These early warning signs tell you that something is not right and action needs to be taken to prevent a setback.

Avoiding Work Avoiding Others _________________

Over or Under Eating Negative Self-Talk _________________

Snapping at Others Self-Harm Thoughts _________________

Not Following Routines Stomachaches/Migraines _________________

Sleep Changes Mood Swings _________________

What are my serious warning signs? Symptoms may progress to the point where they are very uncomfortable, serious, or even dangerous. Being aware of serious signs of a crisis will help gain better control over harmful reactions by being prepared ahead of time with a helpful action plan.

Using/Drinking Paranoia Abuse

Self-Harm Outbursts Neglect

Doing things you are ashamed of Spending Sprees _______________

Road Rage Property Destruction _______________

Threatening Others Hurting Others _______________

What are my current coping skills? This is what I can do to take my mind off the problem. These are things that make me feel better but aren’t dangerous and don’t cause myself or others harm.

Workout/Exercise Quiet Place Relaxation Exercises Yoga/Meditate

Volunteer Self-Talk Journaling Social Interaction

Sleep Hygiene Church Mindfulness Gratitude List

Grounding Techniques 5 Affirmations Shower/Bath/Grooming _______________

Call Supports Distraction Counseling/Support Group ______________

What is my action plan for the crisis I am facing?

Rows	Trigger/Warning Sign	Action Plan or Coping Skill
1
2
3
4
5
6
7

How do I maintain my emotional health and wellness after managing my crisis?
Are there things I need to do to protect my personal and public safety? Inform my colleagues, shop at a different store, take a different route to work, bank somewhere else, locate emergency information and store in safe place.

Who is my Emergency Support?

Rows	Name	Phone
Emergency Contact #1
Emergency Contact #2
Emergency Contact #3

EMERGENCY PREPAREDNESS QUESTIONNAIRE
Please provide us with your updated emergency contact information and contact information of your evacuation destination.
Client's Name:
Emergency Contact Name/Relationship to Client:
Address:
Address: (IF THE ADDRESS IS UNKNOWN, JUST PUT CITY)
Phone:
Phone:
Do you have somewhere to evacuate?
Do you plan to evacuate?
Is yes, when?
Do you plan to return?
Who will you evacuate with?
Do you have the necessities to evacuate?
Do your currently own a cell phone?
If not, whom can we contact to immediately reach you?
What is the best way to contact you?
Amy additional comments / information:
TELEMENTAL HEALTH INFORMED CONSENT
i Client/ Guardian Name*, hereby consent to participate in Telemental health with, IMPACT GROUP BHS, as part of my treatment. I understand that Telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations. I understand the following with respect to telemental health:

1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.

2) I understand that there are risks, benefits, and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

3) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (i.e., mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).

5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required.

6) I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs end and restart the session. If we are unable to reconnect within ten minutes, please call IGBHS office at 225.372.2693 to discuss if we need to re-schedule.

7) I understand that Impact Group BHS may need to contact my emergency contact and/or appropriate authorities in case of an emergency. Emergency Protocols Impact Group BHS need to know are your location in case of an emergency. You agree to inform Impact Group BHS of the address where you are at the beginning of each session. Impact Group BHS also needs a contact person who Impact Group BHS may contact on your behalf in a life- threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency. I have read the information provided above and discussed it Impact Group BHS Authorized Staff. I understand the information contained in this form and all of my questions have been answered to my satisfaction.

The information is provided as a service to ALL members and the social work community for educational and information purposes only and does not constitute legal advice. Impact Group BHS provide timely information, but we make no claims, promises, or guarantees about the accuracy, completeness, or adequacy of the information contained in or linked to this Web site and its associated sites. Transmission of the information is not intended to create, and receipt does not constitute, a lawyer-client relationship between NASW, LDF, or the author(s) and you. NASW members and online readers should not act based on the information provided in the LDF Web site. Laws and court interpretations change frequently. Legal advice must be tailored to the specific facts and circumstances.

Client’s Name: Full Name*   Date:   Date*

Client's Signature: (Signature of Client or Parent/Guardian if client is under 18)*

IGBHS Authorized Staff: _______________________________ Date: _____________________
INFORMED CONSENT FOR MEDICINE
I have the right to refuse medicine, and it cannot be given to me until I talk with my doctor, and I say I am OK with taking the medicine.

My Doctor and I talked about:

1. My diagnosis
2. The reason my doctor wants me to take the medicine, and the chance of me getting better - or not getting better - without the medicine.
3. The fact that I can say NO to the medicine at any time, but I have to tell my doctor.
4. Any other ways to treat my problems.
5. The medicine that I will be taking - the dose, when and how I will take it, and about how long I will need to take it.
6. The side effects for the medicine and any that might be likely in my case - Some medicines may start to hurt my body after I begin taking them, so I may need to have lab tests to make sure I am safe with these medicines. My doctor will talk with me about this if I am taking one of these medicines.

I will talk with my doctor about ALL my medical problems and ANY medicine that I am already taking.

Type Initials* (Initial), I UNDERSTAND IMPACT GROUP BHS DOES NOT PRESCRIBE ANY MEDICATIONS BESIDES MENTAL/BEHAVIORAL HEALTH MEDICATION(S).

CURRENT MEDIATION(S):

Rows	Medication Name	Dose	When	How Many
1
2
3

List Name of Client, (Parent or Guardian if under 18)
Pease select one
Signature for (refuses medicine
Signature for (meds prescribed by provider
Client's Name
Client's Signature (Parent/Guardian if client is under 18)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Prescribing Provider: Monique Williams, APRN, FNP-C, PMHNP-BC
EMERGENCY CONTACT/PRIMARY CARE PHYSICIAN
Client's Name:
EMERGENCY CONTACT INFORMATION

I AGREE (CLIENT/PARENT/GUARDIAN) IN THE EVENT IMPACT GROUP BHS IS UNABLE TO CONTACT (CLIENT/PARENT/GUARDIAN) AT THE INFORMATION YOU PROVIDED, WE MAY CONTACT AND LEAVE A MESSAGE WITH EMERGENCY CONTACT: (A RELEASE WILL BE SIGNED AND PUT ON FILE FOR EMERGENCY CONTACT).
Emergency Contact
Full Name
Relationship to Client:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Physician
Name/Office:
Address (No PO Box):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
Do you give IGBHS Authorized Staff permission to inform you PCP that services are provided:
Client's Name:
Client's Signature (Parent/Guardian if Client is Under age 18)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
IGBHS Authorized Staff:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
GREIVANCE ACKNOWLEDGEMENT
GRIEVANCE ACKNOWLEDGEMENT

When clients/parents/guardians of Impact Group BHS have a grievance concerning the rehabilitation services that they are receiving, they may request in writing a meeting with the Clinical Manager.

By signing below, I acknowledge I am aware and understand

Impact Group BHS, Grievance Policy
Client's Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client's Signature (Parent/Guardian if client is Under Age 18)
I certify that I have explained all rights and responsibilities to Client/Parent/Guardian:

IGBHS Authorized Staff: Signature
Date: Date
CRISIS REPSONSE PLAN ACKNOWLEDGEMENT
I   Client's or (Parent/Guardian if Client is Under Age 18*        , do acknowledge that I am aware and understand Impact Group, BHS’s 24 Hour Crisis Response Plan.
Client/Parent/Guardian understand to contact 911 or report to the nearest emergency room if an emergency arises.
Client/Parent/Guardian understands to contact Impact Group BHS Office or CM in A Non-Emergency situation(s). Impact Group BHS Offices will return your NON-Emergency call within 24 hours.

Client’s Name:   Type client's name*

Client’s Signature:   Signature      Date:   Date*   _____________
IGBHS Authorized Staff:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ORIENTATION ACKNOWLEDGEMENT
By signing below, I acknowledge that I have received a copy of Impact Group BHS Client Handbook.
Client's Name:
Date of Birth
Client's Signature (Parent/Guardian if Client is Under Age 18)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I certify that I have explained ALL Impact Group BHS Policies and Procedures/Rights and Responsibilities to the Client/Parent/Guardian….
IGBHS Authorized Staff:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
CLIENT DRUG SCREEN CONSENT
Initial by each statement for acknowledgement.

Initial I understand that I can be subject to a random drug screen at any given time by Impact Group BHS.
Initial I understand that I may be required to provide proof of prescription(s) or over the counter medication(s) taken before/after the test.
Initial  I understand that testing will be conducted by a third-party facility selected by Impact Group BHS and that such testing will be completed in accordance with applicable law, under procedures established by the laboratory to ensure my privacy while also protecting against tampering/alteration of the test results.

REFUSAL TO TEST

Initial  I understand that if I REFUSE to submit to a random drug screen, I could be subject to being discharged from Impact Group BHS.

TEST RESULTS
Initial   I understand that if any urine drug test results are dilute or dilute negative, I will be required to take a second urine drug test within 48 hours of Impact Group BHS’s receipt of the result. I understand that if the second urine drug test result is also dilute or dilute negative, I will be required to undergo blood drug testing. Blood drug testing must be completed within 24 hours of Impact Group BHS’s receipt of the result.
Initial   I understand that all testing described in this policy acknowledgment form shall be carried out in accordance with applicable law. Should any information in this policy acknowledgment form conflict with any applicable federal, state, or local law, the applicable provision of law will take precedence. I acknowledge that only duly authorized officers, employees, and agents of Impact Group BHS will have access to information furnished or obtained in connection with a substance test I take. I understand that such individuals will maintain and protect the confidentiality of such information to the greatest extent possible.
Initial   I hereby authorize any physician, laboratory, hospital, or medical professional, legal professional retained by Impact Group BHS for testing purposes to conduct such testing and to provide the results to Impact Group BHS. I release Impact Group BHS, any person affiliated with Impact Group BHS, and any such institution or person conducting the testing, from any and all liability which may arise by virtue of such testing and the results therefrom.
Initial   I agreed to hold harmless Impact Group BHS, its company physician, and any testing laboratory Impact Group BHS might use related to the substance testing outlined in this policy acknowledgment. This means that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any other kind of adverse job action that might arise as a result of the substance test, even if Impact Group BHS or its selected laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless Impact Group BHS, its company physician, and any testing laboratory Impact Group BHS might use for any alleged harm to me that might result from the release or use of information or documentation relating to the substance test, if the release or use of the information is within the scope of this policy acknowledgment. This policy acknowledgment has been explained to me in a language I understand, and I have been told that if I have any questions about any substance test or the policy acknowledgment, they will be answered.

Client’s Name:   Type Client's Name
Client's Signature (Parent/Guardian is Under Age 18)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
IGBHS Authorized Staff:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ACKNOWLEDGEMENT OF PRIVACY PRACTICES
By signing below, I acknowledge I have received/discussed Impact Group BHS

“Acknowledgement of Privacy Practices”

CONFIDENTIALITY The security of your sensitive information is of utmost importance to Impact Group BHS, and we are bound by law to protect your confidentiality. Any disclosure of your treatment to others will require your written consent. Basic information about your treatment may be disclosed to your insurance company for purposes of prior authorization if necessary. There are exceptions to this confidentiality, where disclosure is mandatory. These include the following: (BUT NOT LIMITED TOO)

*If there is a threat to the safety of others, I will be required by law to take protective measures including reporting the threat to the potential victim, notifying police, and seeking hospitalization - When there is a threat of harm to yourself, I am required to seek immediate hospitalization, and will likely seek the aid of family members or friends to ensure your safety.

* In situations where a dementing illness, epilepsy or other cognitive dysfunction prevent you from operating a motor vehicle in a safe manner, I will be required to report this to the DMV.

* If a mental illness prevents you from providing for your own basic needs such as food, water, shelter, I will be required to disclose information to seek hospitalization. These situations rarely occur in an outpatient setting. If they do arise, I will do my best to discuss the situation with you before acting.

In rare circumstances I may find it helpful to consult with other professionals specialized in such situations (without disclosing your identity to them).
Client's Name:
Client's Signature: (Parent/Guardian if Client is Under Age 18)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
IGBHS Authorized Staff:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
MEMBER'S CHOICE IN PROVIDER FORM
Member Name:
Member Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Member ID #
Impact Group Behavioral Health Services provides holistic health and human services across the continuum of care by providing community base services and crisis interventions to restore individuals back to function.

The provider I Choose is:

Provider Name: Impact Group BHS Provider Phone: 225.372.2693

By signing below, I acknowledge that I freely choose to receive services from the above provider, and I acknowledge my responsibility to notify my previous provider in order to coordinate care.
Member/Legal Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Legal Guardian Name (if applicable)
Providers: A Choice in Provider Form is required prior to service authorizations. The form requires a member/legal guardian signature, date, and identified provider with telephone number. The provider is responsible for coordinating care with the member’s prior provider.
Provider's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
AUTHORIZATION TO RELEASE - OR - OBTAIN HEALTH INFORMATION
Client Name:
Request Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:
City/State/Zip:
Client's Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medicaid ID OR Last 4 OF SS#
I AUTHORIZE:

NAME: IMPACT GROUP BHS

MAILING ADDRESS: 59335 RIVER WEST DRIVE ∙ BLDG. C SUITE B ∙ PLAQUEMINE, LA 70746

PHONE NUMBER: 225.372.2693 FAX NUMBER: 855.427.3407

RELATIONSHIP: MH/BH/SA

x RELEASE Information TO -OR- X OBTAIN Information FROM
Name:
Mailing Address:
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:
The Purpose of this Authorization is indicated in the box(es) below. (Place an “X” in the box(es) that apply.)

Other
I authorize the release of the following protected health information.(Place an “X” in the box(es) that apply to the information you want released or you want to obtain.)

Other
In compliance with state and/or federal laws which require special permission to release otherwise privilegedinformation, please release the following records.

Other
This authorization shall expire on (date or event)and is needed for the period
beginning type beginning date and ending Type ending date .
I understand that if I do not specify an expiration date, this authorization will expire six (6) months from the date on which it was signed. I acknowledge that I have read both pages 1 and 2 of this form.
Signature of Individual or Personal Representative Authorized by Law
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
2023-2024 RECIPROCAL RELEASE OF INFORMATION/PERMISSION TO ALLOW SERVICES DURING THE INSTRUCTIONAL DAY
This release authorizes blanks School System to release/obtain information to:
Agency Name: Impact Group BHS

59335 River West Drive Building C Suite B

Plaquemine, Louisiana 70764

Phone: 225.218.4775 • Fax: 855.427.3407

This release authorizes the above to release/obtain to:
Name of School System:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
Information as described below pertaining to:
Student's Name:
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
My child is currently in list grade . My child HAS an EP/504 in place: Yes No My child NEEDS an EP/504 Plan in place: Yes No

I, list parent/guardian (Parent/Guardian) give IGBHS Authorized Staff permission to visit with my child at school for services including but not limited to:
• Psychosocial Skills Training

• Service Integration (Observation and Redirection of off-task behaviors)

This agreement will permit the release of the following information to the outside agency providing services on the above-named school campuses: student name, address, date of birth, grades, attendance records, disciplinary records, testing/assessments and reports, IEP and 504 Plans, and other educationally relevant information pertinent to the services provided. This agreement will permit the release of the following information from Impact Group BHS to the named school campus above: copy of the treatment plan, student progress treatment report, and any other safety or educationally relevant information. This information is requested to allow for collaboration between educational and behavioral health service providers and will not be released to any further source or used for any reason other than the purpose stated above. Your signature below provides for the release of this information and grants permission to the school to allow your child to receive these services during the instructional day. It is understood that all missed work must be completed and that services must be scheduled to minimize the effect on academics. The scheduling of these services is at the principal’s discretion. This authorization is effective from the date of the appended signature and will remain in effect for one (1) calendar year. Authorization is subject to written revocation at any time except to the extent that action has already been taken in reliance upon this document. EXPIRATION DATE: (1 YEAR FROM TODAY’S DATE): _____________________
Signature of Parent/Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
WAIVER OF LIABILITY/HOLD HARMLESS AGREEMENT FOR TRANSPORTATION
Please read this form carefully and be aware in signing this waiver to be transported by automobile by an automobile by Impact Group BHS contractor and any activities associated there with will be waving your rights to all claims for injuries you and/or your minor child/ward might sustain arising out of being transported by an automobile by an Impact Group BHS contractor and you will be required to indemnify, hold harmless and defend Impact Group BHS for any claims arising out of you and/or your minor child/ward being transported by an automobile by an Impact Group BHS Contractor. In consideration of my minor child/ward/self being allowed to be transported by an automobile by an Impact Group BHS contractor, as the Parent or Legal Guardian of a participant under 18 years of age, I recognize and acknowledge that there are certain risk of physical injury associated with being transported by an automobile by Impact Group BHS contractor. I agree to assume the full risk of injuries that may be sustained by any child/ward of mine and/or self as a result of being transported by an automobile by an Impact Group BHS contractor. I agree to waive and relinquish all claims on behalf of my minor child/ward/self as a result of the child/ward or self being transported by Impact Group BHS contractor.

I do hereby, fully release end discharge Impact Group BHS and its officers, agents, and employees from any and all claims from injuries, damage, or loss which I, or any child/ward/self may have, or which may occur to my child/ward/self on account of his/her being transported by automobile by Impact Group BHS. I further agree to indemnify and hold harmless and defend Impact Group BHS, its officers, agents, and employees from any and all claims sustained by me or my minor child/ward, and arising out of, connected with, or in any way associated with being transported by automobile by an Impact Group BHS contractor. The invalidity or unenforceability of any of the provisions hereof shall not affect the validity or enforceability of the reminder of the Agreement.

I have read and fully understand the above Waiver and Release of all claims.
Type Name of Client / Parent/ Legal Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
COORDINATION OF CARE FORM
PRACTITIONER/PROVIDER INFORMATION
Provider name:
Contact Person for Provider:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
PATIENT INFORMATION
Patient Name
Patient ID Number or Social Security Number:
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Member's / Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
EXPIRATION: I understand that I may cancel this authorization at any time by sending my healthcare provider(s) my cancellation notices in writing. I understand that my

healthcare provider(s) may have already released records according to this authorization, prior to receiving my written notice to cancel. Unless cancelled, this authorization

expires on (date): _______________________.
IF MEMBER DOES NOT AUTHORIZE RELEASE OF PHI

I DO NOT AUTHOZIE INFORMATION ABOUT MY PHYSICAL AND/OR BEHAVIORAL HEALTH TREATMENT TO BE RELEASED
Member's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
INFORMATION TO BE RELEASED

The only information this Coordination of Care Form authorizes for release is this one-page Notification of Treatment, Including the information below. No additional records will be released without a signed Authorization for Release of Information.

HEALTHCARE COORDINATION INFORMATION

Treatment Start Date:

Medication Managed By:

ICD-10-CM:

TREATMENT PLAN:

MEDICATIONS, IF KNOWN

Confidential Protected Healthcare Information (PHI) enclosed. PHI is personal and sensitive information related to a person’s healthcare. It is being delivered to you after appropriate authorization from the patient/member or under circumstances that do not require patient authorization. You, the recipient, are obligated to maintain it in a safe, secure, and confidential manner. Re-disclosure without additional patient/member consent or as permitted by law is prohibited. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state laws.

FORM INSTRUCTIONS; FAX THIS FORM TO THE PATIENT’S CLINICIAN FOR INCLUSION IN THE PATIENT’S MEDICAL RECORD.
Should be Empty:

INTAKE APPLICATION

CONTACT INFORMATION

EMPLOYMENT/EDUCATION

PRESENTING PROBLEM(S)

PAST TREATMENT

REFERRAL SOURCE/INITIAL ASSESSMENT APPOINTMENT

AUTHORIZATION FOR OUTPATIENT TREATMENT

EMERGENCY PREPAREDNESS QUESTIONNAIRE

TELEMENTAL HEALTH INFORMED CONSENT

INFORMED CONSENT FOR MEDICINE

EMERGENCY CONTACT/PRIMARY CARE PHYSICIAN

Primary Care Physician

GREIVANCE ACKNOWLEDGEMENT

CRISIS REPSONSE PLAN ACKNOWLEDGEMENT

ORIENTATION ACKNOWLEDGEMENT

CLIENT DRUG SCREEN CONSENT

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

MEMBER'S CHOICE IN PROVIDER FORM

AUTHORIZATION TO RELEASE - OR - OBTAIN HEALTH INFORMATION

2023-2024 RECIPROCAL RELEASE OF INFORMATION/PERMISSION TO ALLOW SERVICES DURING THE INSTRUCTIONAL DAY

WAIVER OF LIABILITY/HOLD HARMLESS AGREEMENT FOR TRANSPORTATION

COORDINATION OF CARE FORM