CBH INTAKE FORM - Complete Behavioral Health

CBH INTAKE FORMS

CBH Intake Forms

Welcome to CBH Forms where all the forms are available in one place for your convenience!

We know filling out forms can be a pain. We made it EASY and convenient just for YOU! Forms can be filled online directly (Submit Online) or using fillable pdf or print (Fillable PDF or Print) and fill out with a pen and return to us during your first appointment.

Information you provide here is protected as confidential information. Please complete these forms and bring to your first session.

Intake

Personal Information *

First

Middle

Last

DOB *

Age & Gender *

First

Middle

Last

Address *

City *

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Middle

Last

Phone *

First

Middle

Last

May we leave a message?

Email *

*Please note: E-mail correspondence is not considered a confidential medium of communication.

May we send you emails?

Referred by (if any):

Please list any children/age:

First

Last

Please list any children/age: 2

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Last

Please list any children/age: 3

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Last

Emergency Contact *

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Last

Emergency Contact Numbers *

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Last

Emergency Contact 2

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Last

Emergency Contact Numbers 2

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Last

Emergency Contact 3

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Last

Emergency Contact Numbers 3

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Last

Insurance Information

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Last

Subscriber

Insurance Information

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Middle

Last

Consent For Outpatient Treatment

Consent For Outpatient Treatment *

I, the undersigned Patient, parent, or legal guardian hereby give my consent for and acknowledgment of the following items which are initialed: I understand that I am consenting and agreeing only to those services that the provider is qualified to provide within: (1) the scope of the provider’s license, certification, and training; or (2) the scope of license, certification, and training of the behavioral health care providers directly supervising the services received by the patient. If the patient is under the age of eighteen or unable to consent to treatment, I attest that I have legal custody of this individual and am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual.

Receipt of Rights

I understand that I cannot attend any session or group while I am under the influence of illegal drugs and/or alcohol.
I understand the possible psychological risks involved in counseling. I am hereby forewarned and cautioned, that engaging in psychotherapy may involve discussing uncomfortable past traumatic events, and/or experiencing depression, anger, and other difficult, intense emotions.
I understand that my therapist may work with practicum students, supervisors, and case managers regarding my treatment and/or clinical file.
I understand that case consultation occurs with providers for the sake of learning and improving clinical practice and that my confidential information will not be disclosed.
I understand that certified alcohol and drug abuse counselors, practicum students/interns, and unlicensed professionals do not have privileged communication and may be required if court ordered to testify regarding my treatment.
I understand that audio or video recording of sessions is strictly prohibited unless explicitly agreed upon in writing by both the client and the therapist. Unauthorized recording may result in termination of services and legal consequences.
I understand that I have the right to receive Telehealth services which are available for most insurance plans and are offered through HIPAA compliant, confidential software.
I understand that I need to communicate any concerns or problems to my therapist regarding my treatment and that I am responsible to make change occur. I am also responsible for completing homework assigned by my therapist.

I have read and understand the above initialed items and received an explanation of the information.

First

Last

Personal Representative:

Date:

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Last

Official Financial Policy and Billing Agreement

Client Name (print):

Insurance Coverage:

Client agrees to contact Insurance Company to verify benefits for services rendered. You pay for your Insurance. It is your responsibility to know the benefits of your policy.
Should a dispute arise on a claim, it is generally the clients’ responsibility to clarify and resolve the dispute with the insurance company.
If Insurance is being filed, any deductible not yet met is due at the time of service as well as any co-pay

Payment

Payment is expected at the time of service unless other arrangements have been made.
I agree to provide at least 24 hours’ notice to cancel or reschedule an appointment. If I provide less than 24 hours’ notice, or do not attend the scheduled appointment, late-cancel and/or no-show charges may apply. Fees are as shown:
Initial late cancellation fee $75; $100 for all subsequent late cancellations.
Initial no show fee $100; $150 for all subsequent no shows. I understand that late cancellation fees or no show fees MUST be paid prior to the next scheduled session.
A Service requested by the client, but not covered by the client’s Insurance Plan may be arranged under a separate written agreement with the provider.
Our self-pay fees are $150/session and are subject to change at the discretion of the practice.
Questions regarding your account should be directed to the Billing service at (402) 590 – 2947.
All clients must keep a debit or credit card on file for our office to run copays and other outstanding balances after insurance claims are processed. All clients with balances over $100 will be notified via phone call before a card is run. Please discuss payment plans with your provider.

I certify that I have read, understand and agree to the foregoing. The undersigned is the client or is duly authorized by and on behalf of the client to execute the above and accept its term.

Payment Date:

First

Last

Personal Representative:

Date: 2

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Last

Authorization for Disclosure of Information

Disclosure of Information

Mental Health
Drug/Alcohol
Other

Name (Print):

First

Last

Authorization is hereby given to exchange information in written, verbal or electronic form regarding the above-named individual between the following agencies and/or individuals to be used for the purpose(s) of:

All information requested is covered by federal regulation 45 C.F.R the Health Insurance and Portability Act (HIPAA)

Parts 160 and 164. Drug and alcohol information is covered by federal regulation 42 C.F.R Part 2.

I authorize the following agency or individual (please include address):
To release and/or receive information from the following agency or individual (please include address):

Date:

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Last

Personal Representative

Authority of Personal Representative

Date: 2

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Last

HIPAA Notice of Privacy and Practices

I have reviewed the HIPAA Notice of Privacy Practices information and agree. At my request I am entitled to receive a copy of my rights to privacy.

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Last

HIPAA – Personal Representative

HIPAA – Date 2

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Last

CBH INTAKE FORMS

CBH Intake Forms

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