Helping 2 Overcome Systems LLCYouth Referral Form

Helping 2 Overcome Systems LLCYouth Referral Form
Referral Source
Date of Referral:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Who is your case manager or What program are you participating in?
Referring Counselor/Agency
Counselor/Agency Contact Phone & Email:
Name of School your child attends:
Consumer Information
Consumer's Name:

First NameLast Name
Gender:
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SS#:
Race:
Phone:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian's Name:

First NameLast Name
Phone:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Parent/Guardian – Identification Upload

Please upload your photo ID and your Medicaid Insurance Card

1. Photo ID – Take a Picture or Upload an Image of your Driver License/State ID

2. Medicaid Insurance Card - Take a Picture or Upload an Image of your Medicaid Insurance Card (Front Facing)
Parent/Guardian - Upload your Driver License or State ID and Medicaid Insurance Card File Upload (You may upload more than one image)

Cancelof
Secondary Phone:
Format: (000) 000-0000.
Emergency Contact Name:

First NameLast Name
Phone:
Format: (000) 000-0000.
Relationship to Consumer:
Email:
example@example.com
Reason for Referral:
Insurance Information
Primary Insurance:
Insurance Type:
Member ID #:
Secondary Insurance:
Insurance Type:
Member ID #:
Internal Purposes Only
This section is for internal purposes only.
Date/Notes:
Date/Notes:
Disclaimer and Signature
I understand that my information is being provided to Helping 2 Overcome Systems LLC (H2O) so that a determination for appropriate services can be made. I understand that if I am eligible for services, H2O will utilize the above information to complete initial intake, schedule assessments, and conduct internal affairs in preparation for the provision of services. I also understand that I am required to provide all requested documents including all intake forms and consents, driver's license or identification cards, insurance cards and any other requested documentation upon acceptance into any H2O program.
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed Name:
Phone: 216-312-7678
Address: 23660 Miles Road, Suite 100, Bedford Hts, OH 44128
Fax: 216-208-0627
At, Helping 2 Overcome Systems (H2O), we offer a variety of services aimed at helping you achieve the best outcomes possible. Below is a detailed description of all the services we currently offer. The only service that is required is the initial assessment, where your treatment plan is developed and tailored specifically to you. Please initial next to each service you are interest in receiving if it is deemed medically necessary. If you choose to opt out of any services, you assessor will review these choices with you to ensure you are making informed decisions based on your specific needs. The only service that is required is the diagnostic assessment, where your treatment plan is developed and tailor specially to you.
Therapy initial:
Therapy will be provided by H2O staff. Therapy may consist of group therapy, individual therapy, case management or CPST. Such services will be provided on the days and times identified and agreed upon by both parties. Evidence based curriculum is used for all group services.
Day Treatment initial:
The program provides clinical diagnostic assessment and treatment services that treat anxiety, depression, ODD, ADHD, and trauma and grief disorders. The program serves to improve academic functioning, while simultaneously treating symptoms, and various issues that make it difficult to maintain successful behavior in a regular school setting, being disruptive in the community, and/or having trouble functioning within the family. Common daily treatment encourages skills of anger management, impulse control, social skills, self-esteem, decision-making, communication, and support-seeking skills. The program provides resources and support, as well as evidence-based methods to enable stabilization.
Diagnostic Assessment (required)
Individuals seeking treatment at H2O will participate in a bio-psycho-social assessment. The purpose of this service is to gather information and identify consumer needs. Each consumer has the opportunity to share input regarding his/her needs and preferences. At the beginning of this process, individuals will be given information regarding Duty to Warn,
Revised 7/2025
expectations/requirements for court-referred consumers and information regarding mandated reporting. At the completion of the assessment, the individual and assessor will discuss the course of treatment, family involvement and treatment planning.
Adult and Youth Mental Health Case Management initial:
All individuals will have the opportunity to engage in Community psychiatric supportive treatment (CPST) service. These services include but are not limited to: Ongoing assessment of needs; Assistance in achieving personal independence in managing basic needs as identified by the individual and/or parent or guardian; Facilitation of further development of daily living skills, if identified by the individual and/or parent or guardian; Coordination of the Individual Service Plan (ISP), including services identified in the ISP.
My signature below confirms that I agree to participate and acknowledge receipt of the program expectations and services.
Consumer Name (Print):

First NameLast Name
Consumer Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent / Guardian Name (Print):

First NameLast Name
Parent / Guardian Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Revised 7/2025
3
H2O Consumer Consent to Treat
Consumer Name:

First NameLast Name
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I (we) hereby give my (our) consent to H2O to provide treatment to me (us) and/or for my minor child(ren) which may include but is not limited to various therapies, transportation, psychosocial recreational activities, group activities and case management. The risks and benefits of treatment have been explained to me (us) below. I (we) understand that clinical records will be reviewed by a Quality Assurance Committee and/or in clinical supervision to ensure that quality treatment for my (our) family. Information necessary to carry out treatment, payment, and healthcare operations will be submitted to the appropriate organization for accreditation, certification, or authorization. Additionally, if I (we) apply for all or part of my (our) treatment to be funded by various third parties other than Medicaid, then I (we) understand and agree that information necessary to carry out treatment, payment and healthcare operations will be submitted to those various third parties funding my treatment services. H2O Consumer Grievance Procedures, Consumer Rights and Responsibilities and Notice of Privacy Practices have been explained to me and I have received my own copy. I understand that if H2O Privacy Practices should change, I will be notified of the change by receipt of the new Notice of Privacy Practices. The new Notice of Privacy Practices will also be posted. To provide for minors, H2O requests to obtain consent for treatment from the minor's legal guardian, parent, or custodian but a minor does have the right to consent to their own treatment if over the age of fourteen years.
Risks and Benefits: Behavioral health treatment has both benefits and risks. Risks may include experiencing uncomfortable feelings because the process often requires discussing difficult aspects of one's life. However, treatment has been shown to have benefits. It often leads to a significant reduction in feelings of distress, increased satisfaction in relationships, greater satisfaction and insight, increased skills, and resolution to specific problems. A small number of consumers may not improve because of treatment or may terminate before it is clinically indicated. It is important to keep your clinician advised of any difficulty you may encounter during your treatment.
By signing below, you are attesting that you are legally or custodially responsible for the minor named below.
Signature of Consumer
Printed Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Legal Guardian (if applicable)
Printed Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
WITHDRAWL OF CONSENT OF TREATMENT
You have the right to withdraw consent for treatment at any time. If you choose to withdraw consent, H2O staff will explain any implications or potential consequences for withdrawing treatment. If you chose to withdraw consent for treatment, please sign and date below. I hereby this consent for H2O, to provide treatment efforts have been made to offer help in developing alternative treatment approaches. treatment for myself/my child(ren). The effects of this decision and potential consequences for withdrawing consent have been explained to me.
Revised 7/2025

Authorization to Bill Insurance
Consumer Name

First NameLast Name
DOB:

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

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City:
State:
Zip:
Phone:
Format: (000) 000-0000.
Insurance Company:
Please read check the following:
Name

First NameLast Name
do understand and acknowledge that the H20 staff will submit my claim to the insurance company on my behalf. I further understand that I will be held responsible for any cost incurred during treatment, not covered by my insurance policy or claims, and that I will be responsible for paying all deductibles, fees, co-payments, and co-insurance payments required for myself or my family receiving treatment.
I verify my annual family income for the year
First and Last Name
Type in current year
is estimated to be $
My household consists of (Number of Adults)
Number of Children
Consumer/Guardian Signature
Consumer/Guardian Printed Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
By signing this Authorization to Bill Insurance, you agree to the terms and conditions listed above and you also confirm receipt of a copy of the Authorization to Bill Insurance.
Witness (staff) Signature
Title
Date

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

Medical Emergency Authorization-Youth
Consumer Name:

First NameLast Name
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
*Purpose - To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached. *
Residential Parent/Guardian Name:
Mother's Name:

First NameLast Name
Daytime Phone:
Format: (000) 000-0000.
Father's Name:

First NameLast Name
Daytime Phone:
Format: (000) 000-0000.
Other's Name:

First NameLast Name
Relationship to Child:
Daytime Phone:
Format: (000) 000-0000.
Relative or Care Provider:
Name:

First NameLast Name
Relationship:
Phone:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contacts:
Emergency Contact #1:

First NameLast Name
Phone:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship:
Emergency Contact #2:

First NameLast Name
Phone:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship:
Emergency Contact # 3:

First NameLast Name
Phone:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship:
Emergency contact information is required in accordance with Ohio Administrative Code Rule 3301-3-08 and Rule 3301-32-10 (for school aged children's programs/daycares).
Please complete both pages of the form

PART I OR II MUST BE COMPLETED:
PART I TO GRANT CONSENT
I hereby give consent for the following 911, medical care providers and local hospital to be called during an emergency:
Phone:
Format: (000) 000-0000.
Doctor:
Phone:
Format: (000) 000-0000.
Dentist:
Medical specialist:
Phone:
Format: (000) 000-0000.
Local Hospital:
Phone
Format: (000) 000-0000.
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for:
(1) the administration of any treatment deemed necessary by above-named doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and
(2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
Facts concerning the child's medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted: (Please list all allergies, current medications and medical conditions for your child)
Printed Name:

First NameLast Name
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature:
PART II - REFUSAL TO CONSENT-
I DO NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action (written instructions must be completed):
Printed Name:

First NameLast Name
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature:
Phone:
Format: (000) 000-0000.
Address:
Please complete both pages of the form
Revised 7/2025
7

Telehealth Services Informed Consent
Name:

First NameLast Name
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Definition of Telehealth
Telehealth involves the use of electronic communications to enable professionals to connect with individuals using interactive video and audio communications by using secure platforms which includes Microsoft Teams, Zoom and Google Meets. Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.
I understand that I have the rights with respect to telehealth:
1. I understand privacy and the confidentiality laws apply to telehealth, and that no information obtained through the use of telehealth services will be disclosed to researchers or other entities without my written consent.
2. My health care provider has explained how the videoconferencing technology will be used to conduct a telehealth session, that unlike a direct patient/provider in person, I will not be in the same room as my health care provider.
3. I understand the potential risks to technology including interruptions, unauthorized access and technical difficulties. I understand my health care provider or I can discontinue the videoconference consult/visit if it is believed videoconferencing technologies are not adequate for the situation.
4. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
5. I understand that telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that no results for anticipated benefits can be guaranteed or assured by my provider.
7. I understand my healthcare information may be shared with other individuals for purposes of scheduling and billing. Individuals other than my healthcare provider may be present during the session in order to operate videoconferencing equipment. I further understand that I will be informed of their presence, and that such individuals will maintain confidentiality on information obtained during the session. Furthermore, I have the right to request the following:
- ask non-medical personnel to leave the telehealth examination room; and/or
- terminate the consultation at any time.
8. I agree certain situations - such as emergencies and crisis - are inappropriate for audio-/video-/computer- based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or seek help from a hospital or crisis-oriented healthcare facility in my immediate area.
Consent to The Use of Telehealth
By signing this form, 1 certify:
- That I have read or had this form read and/or had this form explained to me.
- That I fully understand its contents including the risks and benefits of the procedure(s).
- That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Revised 7/2025

Consent to Transport- Youth
Client Name:

First NameLast Name
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
As part of the services provided by H2O, I understand that there may be occasions when H2O will be providing transportation to participate in educational, cultural, therapeutic, and/or recreational activities. I authorize H2O staff and/or volunteers to provide transportation for the stated consumer and understand that H2O is exempt from any liability.
If I refuse to consent to transport, I understand that I will be responsible for transporting the consumer to and from all activities offered by H2O, including field trips, therapy and group sessions, and any other activity that I may attend while enrolled in the H2O programming.
Parent/Guardian Signature
Parent/Guardian Printed Name & Relationship
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Witness Signature
Witness Printed Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Refusal of Authorization:
I refuse to authorize H2O, its staff, or volunteers to provide transportation. I understand that I will be responsible for all transportation to and from all related activities, including therapy and daily group sessions.
Parent/Guardian Signature
Parent/Guardian Printed Name & Relationship
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Witness Signature
Witness Printed Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Revised 9/2025
10
Should be Empty:

Helping 2 Overcome Systems LLCYouth Referral Form

Referral Source

Consumer Information

Insurance Information

Internal Purposes Only

Disclaimer and Signature

H2O Consumer Consent to Treat

WITHDRAWL OF CONSENT OF TREATMENT

Authorization to Bill Insurance

Medical Emergency Authorization-Youth

Residential Parent/Guardian Name:

Relative or Care Provider:

Emergency Contacts:

PART I OR II MUST BE COMPLETED:

PART I TO GRANT CONSENT

PART II - REFUSAL TO CONSENT-

Release of Information-Youth

Purpose or Use of Disclosure: (Please check all that apply)

Re-Disclosure:

Telehealth Services Informed Consent

Definition of Telehealth

I understand that I have the rights with respect to telehealth:

Consent to The Use of Telehealth

Consent to Transport- Youth

Refusal of Authorization: