Patient Intake Form
  • Welcome to Dabney Behavioral Health.

    This comprehensive and secure form is the first and most important step in beginning your care with us. Completing it thoroughly allows us to prepare for your first appointment and tailor our services to your specific needs. Please set aside approximately 45 to 60 minutes to complete this paperwork. Your information is kept strictly confidential and secure. We appreciate you taking the time to complete this, and we look forward to meeting with you.
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  • Contact Information

  • Important Contacts

    Emergency Contact
  • Reason for Seeking Services

  • Insurance, Payment & ID

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  • We require a photo ID to verify your identity and prevent insurance fraud. This is kept securely with your file.

  • Mental Health History

  • Medical History & Substance Use

  • Social & Cultural History

  • Background & Experience

  • Client Demographics

  • Life Experiences

    The following questions ask about potentially difficult experiences. Please answer to the best of your ability. This information helps us better understand your needs and is kept strictly confidential
  • Your Strengths & Goals

  • Patient Portal Usage Agreement

  • Introduction and Purpose

    Welcome to DBHHC's Patient Portal! This portal is your lifeline for accessing services, updating information, and communicating with our practice. Just as you used the portal during the intake process to provide vital information, this process will continue throughout your time as a patient. To ensure uninterrupted services, it's essential to promptly review and update any new documents or information when you log in.

    Patient Responsibilities

    Timely Updates: You are required to review and update your information whenever new documents are made available on the portal. Failure to do so may affect your ability to receive services from DBHHC.

    Emergency Protocol: Please be aware that DBHHC does not provide 24/7 emergency services. If you experience any healthcare emergencies, immediately dial 911 and/or visit your nearest emergency room.

    Telehealth Guidelines

    To ensure a successful telehealth experience, please adhere to the following:

    Appropriate Background: Ensure that your surroundings are appropriate for a clinical session.
    Private Location: Participate in a private setting to maintain confidentiality.
    Preparedness: Be prepared and on time for your scheduled sessions.
    Camera On: Your camera must be on during the session.
    Appropriate Dress: Dress appropriately for a professional setting.
     

    Attendance Policy for Telehealth Sessions

    It is important to attend all scheduled telehealth sessions. Missing three sessions may result in discharge from our services. To avoid a session being marked as missed, patients must notify their therapist prior to the scheduled appointment time if they need to cancel or reschedule.

    HIPAA Compliance

    To maintain the highest standards of patient privacy, please follow these guidelines:

    Communication Guidelines: Do not send personal information via email or SMS texting. Use the secure Messages system within the TherapyNotes Patient Management System for all communications.
    Quality Management: All communication must be HIPAA-compliant to protect your privacy and the integrity of our services.
     

    Mandatory Reporter Disclosure

    As a Mandatory Reporter, I am legally required to report any suspected child or elder abuse or neglect. Reports will be made to the Illinois Department of Children and Family Services for minors or the Illinois Department of Aging for adults. This is done to ensure everyone's safety.

    Additionally, if there is any indication that you are a danger to yourself or others, I am obligated to take appropriate action, which may include reporting to relevant authorities to ensure your safety.

    Crisis Management

    If you or someone in your care is in crisis or experiencing suicidal ideations, please contact the CARES Hotline for a Mobile Crisis Response unit evaluation and/or dial 911:

    CARES Hotline: 1-800-345-9049
    TTY (Toll-Free): 1-866-794-0374
     

    Additional Insurance Information 

    Co-Pay Requirements: If your insurance requires a co-pay, a valid credit card must be on file. The card will be charged after your appointment. If funds are not available, therapy sessions cannot continue.
    Medicaid Insurance: Medicaid typically does not require a co-pay. Although your billing portal may reflect a high cost, this will be adjusted based on insurance payments and other internal adjustments. In most cases, Medicaid patients do not receive a bill.
    Patient Responsibility: If at any time an insurance company fails to pay for services rendered, the patient is responsible for the account balance.

    Acknowledgment and Agreement

    By signing below, you confirm that you understand and agree to the terms outlined in this document. You acknowledge that the patient portal is a critical tool for receiving services and that you will comply with all requirements to maintain access to those services.

    I understand the importance of updating my information promptly.
    I agree to follow the telehealth guidelines and HIPAA compliance policies.
    I acknowledge the crisis management protocol and understand what to do in an emergency.

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