• Park Valley Behavioral Health Care
    The Maxwell Centre, Suite 500
    32 20th Street
    Wheeling, WV 26003

    Please note our accessible parking and entrance
    on the Market Street side of the building.


    Please Note:

    In order to determine whether or not you will be seen in this office, a copy of your insurance card must be included. We will be happy to make a copy for you if you bring your card into the office.

    Feel free to ask for assistance with anything you do not understand.

    If accepted, your first visit is an evaluation to see if it is appropriate to establish a therapeutic relationship.

    Prescribers in this office do not prescribe controlled substances during the first visit.

    Prescribers will not refill controlled substances between scheduled appointments.

    Prescribers in this office check the state prescription monitoring program before prescribing controlled
    substances.

    Prescribers in this office do not prescribe medications to treat pain.

    Our Suboxone Treatment Program includes a requirement of participation in 12 Step Meetings. Please consider your willingness to complete this requirement before taking a packet.

    Thank you very much for your interest in our services!

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Marital Status*

  • If you are a legal guardian of the child, you must bring documentation of order for legal and physical custody to the first appointment in order for the child to be seen.

     

    All children under the age of 18 must be accompanied by a parent or legal guardian to all appointments in our office. Legal guardians must have medical decision making capacity. 

  • Format: (000) 000-0000.
  • *
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you currently pregnant or less than 1 year postpartum and interested in our specialized Perinatal Mental Health Program?
  • Are you interested in more information about our Medication Assisted Treatment Program for Opioid Addiction?
  • Preferred Provider Type(s): Please note Psychiatrist and PA are for medication evaluation and/or management*
  • Will this involve any kind of court case, custody issue, etc?*

  • Note: We are not accepting new patients seeking legal assistance, disability, FMLA or workers' compensation. We will consider assisting patients seeking the above benefits only for established patients who have actively been participating in treatment for a minimum of 1 year. 

  • How did you hear about Park Valley Behavioral Health Care?
  • If your child is accepted as a patient, Would you like appointment reminders?*
  • If accepted as a patient, Would you like appointment reminders?*
  • May we leave a voicemail?

  • Child's Medical History

  • Is your child currently under the care of a pediatrician or family doctor?*
  • Format: (000) 000-0000.
  • Does your child have allergies?*
  • If yes, please list your child's allergies, reactions, and severity of each allergy
  • Is your child currently taking any medications?*

  • Notice: We must have a current list of your medications to consider your application
  • Medication List- Name, Dose, Prescriber, and Date is all required*
  • Check illnesses or conditions your child has been diagnosed with
  • Check illnesses or conditions which have occurred in any of your child's blood relatives

  • Developmental Questions:

  • Is your child potty trained?*
  • Is your child's language age appropriate?*
  • For children who are too young to sit in waiting room alone, can you bring another caregiver to the initial intake appointment? (This is so the provider has time to talk through your concerns about your child in a private setting)*

  • Medical History

  • Are you currently under the care of a physician?*
  • Format: (000) 000-0000.
  • Are you currently under the care of an Obstetrician (OB)?*
  • Are you...
  • Tobacco use*
  • Do you have allergies?*
  • If yes, please list your allergies, reactions, and severity of each allergy
  • Are you currently taking any medications?*

  • Notice: We must have a current list of your medications to consider your application
  • Medication List- Name, Dose, Prescriber, and Date is all required*
  • If it is easier, you can upload a written medication list below. Please ensure it includes medication name, dose, prescriber's name, and approximate date started
  • Check illnesses or conditions you have had diagnosed
  • Check illnesses or conditions which have occurred in any of your blood relatives

  • Please indicate any psychiatric medications you have tried in the past

  • Please indicate any psychiatric medications your child has tried in the past
  • Antidepressants
  • Anti-anxiety medications
  • Antipsychotics
  • ADHD medications
  • Sedative/Hypnotics
  • Mood Stabilizers
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • INSURANCE AUTHORIZATION AND RELEASE:

    I authorize the release of any information, including the diagnosis and records of any treatment or examination rendered to me or my dependents during the period of such care to a third party payers (insurance) and/or other health practitioners as requested.

    I authorize and request my insurance company to pay directly to the doctor or doctor's group insurance benefits otherwise payable to me.

    I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that the patient responsibility is due at the time of service. Any co-pay and past due balance must be paid at the time of service.

    By signing this form, I accept and agree to these polices. My signature indicates my consent to treatment for myself or my dependent. I give consent for the doctor to request my medication prescription history from pharmacies for continuity of care.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • If your child is accepted as a patient, would you like your billing statements emailed to you?*
  • If accepted as a patient, would you like your billing statements emailed to you?*

  • Primary Insurance - Insurance information is required to schedule an appointment

    (If no insurance, type "self pay")
  • Insurance effective date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Responsible Party Information (Person who holds the insurance)
  • Relationship to Insured:*
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • If you are able to do so, please upload your insurance card
  • Front of Insurance Card
  • Back of Insurance Card
  • Is the patient covered under a secondary insurance?*

  • Secondary or Additional Insurance

  • Insurance effective date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Responsible Party Information (Person who holds the insurance)
  • Relationship to Insured:*
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • If you are able to do so, please upload your insurance card
  • Front of Insurance Card
  • Back of Insurance Card
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Office Policies

    Thank you for selecting use as your provider for psychiatric services. We look forward to working with you in helping you attain your goals.

    Please read the following information and sign below to indicate your understanding and agreement to abide by our policies.

    CONFIDENTIALITY

    Your privacy is an important component of your treatment. No one other than office personnel will have access to your file, without your consent, except in the following situations:


    1) Future harm being threatened by client to self or someone else will be reported.

    2) Criminal activity on our premises or targeting our personnel will be reported.

    3) Child or disabled adult neglect or abuse must by law be reported to Protective Services.

    4) Court ordered or subpoenas of records may occur.

    Should any of the above conditions occur that necessitate breach of your confidentiality, you will be informed immediately.

    EMERGENCIES

    Should a crisis arise during office hours, please call 304-218-2023. The office staff will assist you in reaching your provider or refer you to the appropriate facilities. When the office is closed, an answering service is utilized, which can be reached at 304-218-2023.

    Please use the answering service for EMERGENCIES only. The answering service will not take messages regarding scheduling or medication refills.

    SCHEDULING

    We do our best to schedule you promptly. If an unavoidable conflict arises, please call the office during business hours or text us as soon as possible. Please see our No Show Policy below for more information about changing and/or missing appointments. Our office hours are Monday to Thursday, 9:00am to 4:00pm, and Friday 9:00am to 3:30pm, except from 12:00pm to 1:00pm daily. We are closed for major holidays.


    NO SHOW POLICY

    New patient evaluation
    If you cancel your initial appointment at least 24 business hours before the appointment date and time, you can re-schedule after six months. If you late cancel or no show your initial appointment, you must re-apply after one year.

    Established patients
    We understand that circumstances arise that do not allow you to keep your appointments, but please remember to be courteous by calling the office staff at 304-218-2023 at least 24 business hours prior to your appointment time to cancel if you cannot make it.

    Our business hours are Mon-Thurs 9am-12pm and 1pm-4pm and Fri 9am-12pm and 1pm-3:30pm. Our answering service is for handling urgent medical issues only and is not authorized to take cancellations. At this time, we do not have an encrypted email service.

    This practice is operating with a waiting list of people in need who could greatly benefit from your providing at least 24 business hours notice to cancel your appointment.

    First and second missed appointments: A $45 fee may be applied to your account that should be paid in full prior to being seen for an appointment again.

    Third missed appointment: At this point, since you have not been consistently active in your treatment, we have not been able to meet your needs, and you may be discharged. You will be notified by mail.

    Most of our clients at Park Valley will not miss an appointment, so this will not be an issue. If you call and cancel at a time that gives the office notice, we can fill your spot with a client that may have been denied an appointment. If you have questions, please talk to any of the staff at Park Valley.

    We appreciate that you have chosen us as your provider(s).

    FORMS

    There may be a $10.00-$25.00 fee for form completion. If charged, this payment is your responsibility. Forms will be completed only at the time of regulary scheduled treatment appointments, if your provider agrees to your request. 

    PAYMENT

    You are financially responsible for treatment fees. Payments for co-pays are required at the time of service. If you have a balance after the insurance pays, you will be billed and expected to pay the balance within 30 days. Please let us know if you need a payment plan, and all efforts will be made to reach a reasonable agreement.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Park Valley Behavioral Health Care No Show Policy

  • New Patient Evaluation

    Please ensure you schedule your evaluation appointment at a good time for you, they can NOT be rescheduled. If you cancel your initial appointment at least 24 hours before the appointment date and time, you are able to re-schedule your evaluation after six months. If you late cancel (less than 24 hours of your appointment) or no show your initial appointment, you must re-apply after one year.

    Established patients

    We understand that circumstances arise that do not allow you to keep your appointments, but please remember to be courteous by calling the office staff at (304) 218-2023 at least 24 business hours prior to your appointment time to cancel if you cannot make it. Our business hours are Monday-Thursday 9am-12pm and 1pm-4pm and Friday 9am-12pm and 1pm-3:30pm. Our answering service is not authorized to take cancellations.

    If you recieve text message appointment reminders, you may respond to the text with a message to cancel at least 24 business hours prior to your appointment. 

    This practice is operating with a waiting list of people in need who could greatly benefit from you providing 24 hours notice to cancel your appointment. Same day cancellations are counted as missed appointments.

    First and second missed appointments: A $45.00 no show fee may be applied to your account that you must pay in full prior to being seen for an appointment again.

    Third missed appointment: At this point, since you have not been consistently active in your treatment, we have not been able to meet your needs, and you may be referred elsewhere for treatment. Other options will be provided to you with names and phone numbers of other providers.

    If you have questions, please talk to any of the staff at Park Valley. We appreciate that you have chosen us as your provider(s).

    Note: Outgoing text appointment reminders are automated. You may text us, and we will attempt to respond to your message within 1 business day. 

    Your signature below indicates that you have read and understand the terms and conditions of the No Show Policy.

     

    *Please note that patients enrolled in Park Valley's Suboxone Treatment Program should refer to their treatment contract for program specific policy regarding missed appointments.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Park Valley Behavioral Health Care

    Payment Policy

    Effective Date: 11/01/2024

    Purpose: To outline our payment policy, including procedures for handling account balances over $150.00.

    1. Payment Responsibility

    •  Insurance Coverage: As a courtesy, we will bill your insurance company directly. However, it is your responsibility to understand your insurance benefits and to pay any co-payments, co-insurance, deductibles, no-show fees, or other charges not covered by your insurance.
    • Account Balances: After your insurance has processed your claim, any remaining balance becomes your responsibility. This includes balances resulting from services not covered by your insurance or if your insurance denies a claim.
    • Due Date: Payment is due within 30 days of the statement date. If you are unable to pay the full amount, please contact our billing office immediately to discuss payment options.

    2. Balances Over $150.00

    • Notification: If your account balance exceeds $150.00, you will be expected to pay the balance in full. If payment is not received, appointments may be canceled until payment is submitted. This balance may not include pending charges that have not yet been finalized with your insurance provider.

    3. Payment Options

    • Methods of Payment: We accept the following forms of payment:
    • Credit/Debit Cards (Visa, MasterCard, American Express, Discover)
    • Personal Checks
    • Money Orders
    • Cash
    • Online Payments: If you receive email statements, you may be eligible to pay your balance in full online.  See your statement header for instructions.

    4. Payment Plans

    • Eligibility: If you are unable to pay your balance in full, we offer payment plans for balances over $150.00. Payment plans must be arranged before the due date of the outstanding balance.

    Terms and Conditions:

    • Initial Payment: A minimum initial payment of 25% of the total balance is required to set up a payment plan.
    • Monthly Payments: The remaining balance can be divided into equal monthly payments, typically over a period of 6 months.
    • Automatic Payments: To ensure timely payments, we strongly encourage setting up automatic monthly payments through a credit or debit card.
    • Agreement: A payment plan agreement will be documented and signed by both the patient and a representative of our office. The agreement will outline the payment schedule, amounts, and due dates.
    • Late Payments: If a payment is missed or late, the payment plan may be voided, and the full balance may become due immediately.

    5. Outstanding Balances and Collections

    • Account in Good Standing: To continue receiving medical care, your account must be in good standing. This means either having a balance below $150.00, being up to date on a payment plan, or having paid the balance in full.
    • Collections: Accounts with balances over $150.00 that remain unpaid for more than 90 days may be turned over to a collection agency. Additional fees may apply, and your credit rating could be affected.

    6. Financial Hardship

    • Assistance Programs: If you are experiencing financial hardship, please contact our billing office to discuss possible assistance options. We are committed to working with you to find a solution.

    7. Contact Information

    • If you have any questions regarding your account, or if you need to set up a payment plan, please contact our billing office at:
      • Phone: 304-218-2023- Option 3
      • Office Hours: Monday to Thursday, 9:00am to 4:00pm, and Friday 9:00am to 3:30pm, except from 12:00pm to 1:00pm daily. 

     

    Acknowledgment:

    By receiving services at Park Valley Behavioral Health Plan, you acknowledge that you have read and understand this payment policy and agree to abide by its terms.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • This policy is designed to ensure that our office can continue providing high-quality care to all patients. We appreciate your cooperation and understanding.

  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    *You May Refuse to Sign This Acknowledgement*

  • I *, have received a copy of this office's Notice of Privacy Practices.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS

    I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care and treatment.

    I understand that this information serves as:

    • A basis for planning my care and treatment.
    • A means of communication among the many healthcare professionals who contribute to my care.
    • A source of information for applying my diagnosis and surgical information to my bill.
    • A means by which a third-party payer can verify the services billed were actually provided.
    • A tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare professionals.

    I understand that I have the right:

    • To object to the use of my health information for directory purposes
    • To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations - and that the organization is not required to agree to the restrictions requested.
    • To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Edinburgh Postnatal Depression Scale (EPDS)

    Please select the answer that comes closest to how you have felt IN THE PAST 7 DAYS—not just how you feel today
  • 1. I have been able to laugh and see the funny side of things:
  • 2. I have looked forward with enjoyment to things:
  • 3. I have blamed myself unnecessarily when things went wrong:
  • 4. I have been anxious or worried for no good reason:
  • 5. I have felt scared or panicky for no good reason:
  • 6. Things have been getting to me:
  • 7. I have been so unhappy that I have had difficulty sleeping:
  • 8. I have felt sad or miserable:
  • 9. I have been so unhappy that I have been crying:
  • 10. The thought of harming myself has occurred to me:

  • Mood Disorder Questionnaire (MDQ)

  • Instructions: Please select the answer that best applies to you. Please answer each question as best you can. 

  • 1. Has there ever been a period of time when you were not your usual self and...
    Rows
  • 2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?
  • 3. How much of a problem did any of these cause you — like being able to work; having family, money, or legal troubles; getting into arguments or fights?
  • 4. Have any of your blood relatives (ie: children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
  • 5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?

  • Before hitting the Submit Button below, please take the time now to add our office phone number to your contacts so you will know when one of our office staff reaches out to you. (304) 218 - 2023 We do our best to contact you within seven to ten calendar days of the day you submit your information. Thank you.
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