DBH Intake Form

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

First NameMiddle InitialLast Name
Preferred Name:
Gender:
Birthdate:

MonthDayYear
Date
Age:
SSN:
Marital Status:
Home #:
Format: (000) 000-0000.
Cell #:
Format: (000) 000-0000.
Home Address:*
City, State, Zip:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:
Employer:
Work #:*
Format: (000) 000-0000.
Ext:
Would you like to receive appointment reminders?
Please select which phone number you would like to be contacted for appointment reminders:
If you wish to receive appointment reminders by email, please provide your email below:
example@example.com
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?
Mental Health History
Have you 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
Services Ended
Have you ever been hospitalized for mental health reasons?
If yes, When?
Where?
Length of stay:
Reason for Hospitalization:
Medical History
Primary Care Physician:
Office Address:
City, State, Zip:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone #:
Format: (000) 000-0000.
Fax #:
Format: (000) 000-0000.
Please list ALL current medications, dosage, and prescribing doctor:
Emergency Contact:
His/her Name:
Relation:
Home#:
Format: (000) 000-0000.
Cell#:
Format: (000) 000-0000.
Patient Name:
DOB:

MonthDayYear
Date

Responsible Party (if different from patient)
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)
Are these visits covered by Employee Assistance Program (EAP) benefits?
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
Primary Insurance
Insurance Company:
Policy ID#:
Policy Holder:
Gender:
Relation:
DOB

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Contact #:
Secondary Insurance
Insurance Company:
Policy ID#:
Policy Holder:
Gender:
Relation:
DOB

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Contact #:
I hereby authorize DBH to release necessary medical information to my insurance company. I further authorize direct payment to the above entities from the above listed company. I understand that I am responsible for obtaining referrals, if necessary, and paying and co-payment, co-insurance, or deductibles required by my Plan. I also understand that I may be responsible for the full amount in the event of non-coverage determined by my plan. If my account is not paid when due, I further agree to pay any collection expenses upon my account being turned over to the Credit Adjustment Board. I further understand that it is my responsibility to notify DBH when/if my insurance changes.
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. I I further understand that I may request a full copy of DBH's financial agreement at any time.
Patient Signature:

Clear
Date:

MonthDayYear
Date
Patient Name:

First NameLast Name
DOB:

MonthDayYear
Date

Consent for Treatment
I, the undersigned, do voluntarily consent to psychiatric/behavioral health assessment and/or treatment for myself.
By signing below, I authorize Dominion Behavioral Healthcare to provide psychiatric and/or behavioral health assessment and exams, treatment, and/or diagnostic procedures which now, or during the course of my treatment, become 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 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 I have or that develop over the course of treatment, and to make my physician aware of any other medications, including over-the-counter medications or herbal supplements that I am taking. I also understand that discontinuation of medication should be discussed in advance with my physician.
I understand that it is my responsibility to inform my physician or therapist if I feel 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 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 treating clinician is required by law to maintain privacy of my mental health record and to provide me with notice of their legal duties and privacy practices with respect to my 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 sessions with my treating clinician.
I understand that I have the right to disagree with decision made and I can make a formal complaint to a Dominion Behavioral 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 I am still in treatment at DBH then I will be notified in person and writing about such changes.
I acknowledge that I have been notified of the HIPAA policy and may request a complete written copy at any time.
Patient Signature:

Clear
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 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,
certify that I am 18 years old or older and give permission for Dominion Behavioral Healthcare to communicate with the following persons about my treatment:

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

I DO NOT authorize DBH to release any information
Please initial
Patient Signature:

Clear
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:

I give Dominion Behavioral Healthcare permission to exchange my protected health information to the following providers:
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:
Patient's Signature

Clear
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:
Seen by:
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
Patient Full Name:

First NameLast Name
DOB:

MonthDayYear
Credit Card Holder's Signature:

Clear
Date:

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

*FOR MEDICARE PATIENTS ONLY*
*FOR MEDICARE PATIENTS ONLY*
DOMINION BEHAVIORAL HEALTHCARE
Dear Patient,
We hope this letter finds you well. As part of our ongoing commitment to providing comprehensive and coordinated healthcare, we would like to inform you about additional support available to help manage your chronic health conditions. Our records show that you are currently being treated for two or more chronic conditions, such as diabetes, hypertension, bipolar disorder, depression, etc. Managing multiple health concerns can be challenging, and we want to ensure you have the personalized care and attention you deserve. To better support your health, we offer a Chronic Care Management (CCM) program. This program provides:
- Monthly check-ins with our care coordination team
- Personalized care plans tailored to your specific health goals
- Medication review and management to help avoid interactions or complications
- Coordination between your primary care provider and any specialists you see
Participation in this program is voluntary, and most insurance plans - including Medicare cover it, often with little or no out-of-pocket cost. If you would like more information, please call our office at 804-271-1124 or speak with your provider during your next appointment. We are here to make your care easier, more connected, and more effective. If you choose to discontinue this service at any time for any reason, please ask any of our staff members for the CCM termination form. Thank you for trusting us with your healthcare. We look forward to continuing to support you in managing your health and improving your quality of life.
YesNo
Patient Signature

Clear
Date

MonthDayYear
Date
Main Office and TMS Center
Pembrooke Medical Center
2301 N. Parham Road, Ste 5
Richmond, VA 23229
(804) 270-1124
Fax: (804) 270-2090
Psychiatrists
**Neurostar TMS Certified
SPRAVATO REMS Certified
Ashvin Patel, M.D., D.L.F.A.P.A**
Jhansi Mead, M.D.
Manish Soni, M.D.
Nurse Practitioners
Abbie Smith, PMHNP-BC
Jeff Semler, PMHNP-BC
Kim Southam-Gerow, PMHNP-BC**
Samantha Hasenzahl, PMHNP-BC
Lauren McManamay, PMHNP-BC
Monica Meyer, PMHNP-BC
Thomas Mamalakis, PMHNP-BC**
Psychologist
Bob Marcello, PHD
Byron Williams, Psy.D., LCP
Michelle L. Sullivan, Psy.D., LCP
Susan Reeves, Psy.D., LCP
Clinicians
Ashley Hall, LCSW
Barbara D. Kaplan, LPC
Carolyn Clarke, LCSW
Christine Gray, LCSW
Elizabeth Goodman, LCSW
Erica Jackson, LCSW
Gordon Harrower, LCSW
Jean M. Skrincosky, LCSW
Jim Willis, M.S., LPC
John Hamlett, LPC
Lowell E. Thomas, LPC, LMFT, CT
Martha M. Campbell, LCSW
Patricia L. Mullen, LPC
Stephanie Smith, LPC
Taylor Scarce, LCSW
Should be Empty:

Adult Intake Forms

Patient Demographics

Mental Health History

Medical History

Emergency Contact:

Responsible Party (if different from patient)

Employee Assistance Program (EAP)

Primary Insurance

Secondary Insurance

Have you had any of the following problems recently?

Lifestyle Questions

Consent for Treatment

Authorization to Release Information

Consent for Coordination of Care

Below for office use only

DBH

Credit Card on File Agreement

All Information Must Be Completely Filled In Below

FOR MEDICARE PATIENTS ONLY

Main Office and TMS Center

Psychiatrists

Nurse Practitioners

Psychologist

Clinicians

Adult Intake Forms

Patient Demographics

Mental Health History

Medical History

Emergency Contact:

Responsible Party (if different from patient)

Employee Assistance Program (EAP)

Primary Insurance

Secondary Insurance

Have you had any of the following problems recently?

Lifestyle Questions

Consent for Treatment

Authorization to Release Information

Consent for Coordination of Care

Below for office use only

DBH

Credit Card on File Agreement

All Information Must Be Completely Filled In Below

*FOR MEDICARE PATIENTS ONLY*

Main Office and TMS Center

Psychiatrists

Nurse Practitioners

Psychologist

Clinicians

FOR MEDICARE PATIENTS ONLY