DBH Intake Form

DOMINION BEHAVIORAL HEALTHCARE
West End Office
2301 N. Parham Road, Suite 5 Richmond, VA 23229
Phone: (804) 270-1124
Fax: (804) 270-2090
Child/Adolescent Intake Forms
Patient Demographics
Name:*

First NameMiddle InitialLast Name
Preferred Name:
Gender:
Birthdate:

MonthDayYear
Date
Age:
Home #:
Format: (000) 000-0000.
Cell #:
Format: (000) 000-0000.
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School/Grade:
Primary Insurance
Insurance Company:
Policy ID#:
Policy Holder:
Gender:
DOB:

MonthDayYear
Date
Relation:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Contact #:
Parent/Legal Guardian Information:
Relation:
Name:
Birthdate:

MonthDayYear
Date
Gender:
SSN:
Address (if different):
Relation:
Name:
Birthdate:

MonthDayYear
Date
Gender:
SSN:
Address (if different):
Secondary Insurance
Insurance Company:
Policy ID#:
Policy Holder:
Home #:
Format: (000) 000-0000.
Cell #:
Format: (000) 000-0000.
Gender:
DOB:

MonthDayYear
Date
Relation:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Contact #:
Home #:
Format: (000) 000-0000.
Cell #:
Format: (000) 000-0000.
Emergency Contact:
Their Name:
Relation:
Home#:
Format: (000) 000-0000.
Cell#:
Format: (000) 000-0000.
Would you like to receive appointment reminders? Please select which phone number you would like to be contacted forappointment reminders:
If you wish to receive appointment reminders by email, please provide your email below:
I give permission for relevant confidential information to be left on my home answering machine and/or cell voice mail?
Who referred you to our practice?
Were you referred to a specific provider at DBH?
If yes, which one?
Patient Name:
DOB:

MonthDayYear
Date
1

Responsible Party
Name:*

First NameLast Name
DOB:

MonthDayYear
Date
Relation to Patient:*
SSN:
Billing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact #:
Format: (000) 000-0000.
Email:
example@example.com
Employee Assistance Program (EAP)
YesNo
If yes, please provide the following information:
Name of EAP company:
Authorization #:
Allotted Number of Visits:
EAP Start Date:

MonthDayYear
Date
EAP End Date:

MonthDayYear
Date
Mental Health History
Has your child received counseling, psychological, or psychiatric services in the past?
If yes please provide the Professional's Name and dates of treatment below:
Name of Professional
Service Began

MonthDayYear
Date
Services Ended

MonthDayYear
Date
YesNo
If yes, When?
Where?
Length of stay
Reason for Hospitalization:
Medical History
Pediatrician's Name:
Office Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone #:
Format: (000) 000-0000.
Fax #:
Please list ALL current medications, dosage, and the prescribing doctor:
No insurance information provided?
I understand that the following charges are not covered by insurance: $20-Medication Refill Fee, $75-No Show/Late Cancellation Fee (we require 24 hours notice for a cancellation) $90-Bariatric Form Writing Fee. $120 (per hour)-Completion of Paperwork/ Letter Writing Fee. For other fees not covered by insurance please refer to the financial agreement. Il further understand that I may request a full copy of DBH's financial agreement at any time.
Patient Signature (if 14 or older) :
Date:

MonthDayYear
Date
Parent/Guardian Signature:
Date:

MonthDayYear
Date
Patient Name:

First NameLast Name
DOB:

MonthDayYear
Date

Lifestyle Questions
Nutrition:
Do you eat a healthy, well balance diet most of the time?
Would you like to improve your diet?
Are you currently dieting:
Exercise:
I exercise regularly
If yes, approximately how many days per week do you exercise:
Sleep:
Insomnia?
Sleep Too Much?
Average hours nightly
Do you take medication to help you sleep?
Smoking: Do you smoke, chew or vape tobacco?
Average used daily
If yes, are you interested in stopping?
Social Network:
Do you engage in positive daily social interactions?
Do you have anyone you feel comfortable confiding in?
Hobbies:
Do you have any hobbies you enjoy participating in on a regular basis?
Stress Management:
Do you feel under stress?
If yes, answer the following questions:
Do you have specific ways of reducing stress?
Example:
Would you like to learn new/additional ways of reducing stress?
Alcohol:
Do you drink alcohol?
Beer
Wine
Liquor
Least per day:
Most per day:
Do you typically drink more on weekends?
Non-Prescription Drugs:
Type of drug(s)
Spiritual Practices:
Do you have a belief system that helps to support your life?
Please list any areas that you would like to discuss in therapy:
**For Clinician Use Only** Notes on any issues addressed in treatment:
Patient Name:
DOB:

Consent for Treatment
I, the undersigned, am the parent/legal guardian of ____________________ (patient's name), do voluntarily consent to psychiatric/behavioral health assessment and/or treatment for him/her.
Patient's Name:
By signing below, I authorize Dominion Behavioral Healthcare to provide psychiatric and/or behavioral health assess- ment and exams, treatment, and/or diagnostic procedures which now, or during the course of my child's treatment, be- come advisable. I understand that the purpose, potential risks and benefits, and alternatives to any treatment, as well as the risks of not having treatment, will be explained to me upon my request, and that I can always decline treatment.
I understand that while my child's treatment will be designed to help me, there is no guarantee of a successful outcome.
Psychotherapy involves risks, such as but not limited to, the development or worsening of emotions such as anxiety, sadness and anger. I understand that this is a normal response to working through life experiences and that these reactions should be discussed with my therapist or physician.
Treatment with Medication also has certain risks, varying with the type of medication prescribed, which will be explained to me. I know that taking a medication of any kind always carries the risk of a potentially fatal allergic reaction. I understand that it is my responsibility to make my physician aware of any health conditions that my child has or that develop over the course of treatment, and to make my child's physician aware of any other medications, including over- the-counter medications or herbal supplements that he/she is taking. I also understand that discontinuation of medication should be discussed in advance with my child's physician.
I understand that it is my responsibility to inform my child's physician or therapist if my child feels worse in response to any treatment provided, including but not limited to, the development or worsening of suicidal ideation, depression, agitation, anxiety, insomnia, irritability or mania, especially if these reactions are new, severe, or abrupt in onset.
I understand that as part of my child's mental health care, Dominion Behavioral Healthcare originated and will maintain paper and/or electronic records describing treatment, testing results and forms, correspondence and insurance information. Except when required by law, this information cannot be disclosed without my written consent. I may revoke any authorization for disclosure at any time except if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
I further understand that I may request a complete copy of Dominion Behavioral Healthcare's Privacy Practices at any time.
I understand that my child's treating clinician is required by law to maintain privacy of his/her mental health record and to provide me with notice of their legal duties and privacy practices with respect to my child's mental health record. The treating clinician has the right to change those privacy policies and practices with notification to you in writing.
I understand that at no time, am I permitted to record video and/or audio of my child's sessions with their treating clinician.
I understand that I have the right to disagree with decision made and I can make a formal complaint to a Dominion Be- havioral Healthcare Privacy Officer at (804) 270-1124. A written complaint can be made to the Secretary of the U.S. Department of Health and Human Services.
I understand that this notice is in effect beginning January 1, 2018. If there are any changes to this notice while my child is still in treatment at DBH then I will be notified in person and writing about such changes.
Patient Signature (if 14 or older)
Date:

MonthDayYear
Date
Parent/Guardian Signature:
Date:

MonthDayYear
Date
Patient Name:
DOB:

MonthDayYear
Date

Authorization to Release Information
In accordance with HIPAA privacy laws, a signed consent form is required to release information in any form about your child's care. This authorization allows us to communicate when needed or requested regarding scheduling, insurance or billing information, as well as routine or emergency contact. This authorization may be rescinded or amended at any time that you choose. Please use the space below to identify any family, friend or medical professional with whom you may want us to have contact. I, the undersigned, certify that I am the legal guardian of
and give permission for Dominion Behavioral Healthcare to communicate with the following persons about my child's treatment:

Rows	Name	Relationship	Phone
1)
2)
3)
4)
5)
6)
7)
8)

I DO NOT authorize DBH to release any information.
Patient Signature (if 14 or older):
Date:

MonthDayYear
Date
Parent/Legal Guardian Signature:
Date:

MonthDayYear
Date
Patient Name:
DOB:

MonthDayYear
Date

Consent for Coordination of Care
PATIENT NAME:

First NameLast Name
DATE OF BIRTH:

MonthDayYear
Date
*In order to provide the best care possible. your physician and/or clinician would like to be able to communicate with your other treating medical professionals.
*Most insurance companies require this information exchange.
*Please check one of the following and sign.
Permission to exchange information:
Primary Care Doctor's Name:
Phone #:
Format: (000) 000-0000.
Fax #:
Format: (000) 000-0000.
Address:
Psychiatrist's Name:
Phone#:
Format: (000) 000-0000.
Fax#:
Format: (000) 000-0000.
Address:
Psychotherapist's Name:
Phone #:
Format: (000) 000-0000.
Fax #:
Format: (000) 000-0000.
Address:
Or Waive Notification:
I waive notification of my child's PCP that he/she seeking or receiving mental health services, and I direct you NOT to so notify him/her.
Patient Signature (if 14 or older):
Date:

MonthDayYear
Date
Parent/Legal Guardian Signature:
Date:

MonthDayYear
Date
Below for office use only
Date:

MonthDayYear
Date
Dear:
In an effort to coordinate care, we are writing to inform you that the above-named individual was seen by: for an initial assessment/treatment. The initial assessment reveals:
Any medications provided are listed below:
Sincerely,
Patient Name:

First NameLast Name
DOB:

MonthDayYear
Date

DBH
Credit Card on File Agreement
We have implemented a policy which enables you to maintain your credit card information securely on file with Dominion Behavioral Healthcare ("DBH"). In providing us with your credit card information, you are giving DBH permission to automatically charge your credit card on file for your (or any other patient(s) you have listed on this form) co-pays/co-insurance, outstanding balances, missed/ canceled appointment fees, services, and/or products.
Co-Pays/ Co-Insurance: Co-pays and co-insurances are due at the time of the office visit. You may still choose to make your payment by check, cash, or a card different from the credit card on filc.
Outstanding Balance: If your insurance provider has paid their portion of your bill (or any other patient(s) you have listed on this form) and there is still an outstanding balance owed, DBH will charge the card listed below. By signing this form, you give permission for DBH to charge your card for any outstanding balance on your (or any other patient(s) you have listed on this form) account, including missed/canceled appointment fees, contact fees, and outstanding co-pays/co-insurances.
Services and Products: Self pay services and other fees are due at the time of the office visit.
This card will only be authorized for the use of the credit card holder or any person(s) listed below by the credit card holder. This agreement will expire upon termination of services and settlement of final balance. The card holder may also revoke this consent at any time in writing while understanding that continued services may not be available if an unpaid balance accrues.
All Information Must Be Completely Filled In Below
VisaMasterCardDiscoverAmerican ExpressHSA/FSA
Billing Zip Code:
Expiration Date:

MonthDayYear
Please fill out the information below for any other person(s) for whom you authorize use of this credit card. If NO OTHERS ALLOWED, check the box below and initial.
No others allowed
Initials:
Patient Full Name:

First NameLast Name
DOB:

MonthDayYear
Date
Patient Full Name:

First NameLast Name
DOB:

MonthDayYear
Date
Credit Card Holder's Signature:
Date:

MonthDayYear
Date
2301 N. Parham Rd, Suite 5, Richmond, VA 23229 | Phone: 804-270-1124 | Fax: 804-270-2090
Should be Empty:

Child/Adolescent Intake Forms

Patient Demographics

Primary Insurance

Parent/Legal Guardian Information:

Secondary Insurance

Emergency Contact:

Responsible Party

Employee Assistance Program (EAP)

Mental Health History

Medical History

Lifestyle Questions

Consent for Treatment

Authorization to Release Information

Consent for Coordination of Care

DBH

Credit Card on File Agreement

All Information Must Be Completely Filled In Below