Informed Consent for Behavioral Health TreatmentConsent to Services: I voluntarily consent that I will participate in a behavioral health treatment (e.g. psychological or psychiatric) by staff from the Cognitive Behavior Institute; Psych-Med Associates; Jennifer Almendrala MD, LLC; Peter Murray MD, LLC; and/or Blackbird Health, LLC. Treatment may be provided by a licensed counselor, a psychologist, a psychiatric nurse practitioner, a psychiatrist, or an individual supervised by any of the professionals listed. Services may include interviews, assessment or testing, psychotherapy, and/or medication management.Risks & 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 awareness and insight, increased skills and resolutions to specific problems. A small number of clients 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.Person Financially Responsible for Account: The undersigned hereby agree to be financially responsible for this account.Name*DOB* Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneCell PhoneEmail* Client Name different? Client Name:DOB Insurance Information: Please complete and provide a copy of your insurance card to office staff.Name of Policy HolderMember IDGroup NumberPhone Number of InsuranceSecondary Insurance Information: (if applicable) Name of Insurance:Name of Policyholder:Member IDGroup Number:Phone Number of Insurance:Credit Card Information: In accordance with our Financial Obligation Policy, please complete the information below in. This information is kept secure in our electronic client Vault.Name on Credit CardCard NumberExp DateCVV Code (on back)Did you receive a referral through an Employee Assistance Program (EAP)?YesNoName of Employer:EAP Name:EAP Phone Number:Authorization Number:Number of Sessions:Emergency Contact: Please provide contact information for someone we may contact on your behalf.Name:Phone NumberRelationship to Patient:Name:PhoneRelationship to Patient:Expiration of Consent: This consent will expire at the time of discharge from behavioral health services from the Cognitive Behavior Institute.Attestation of Informed Consent: Information regarding our policies and procedures is provided as part of this informed consent. Please review these documents carefully and check below. Your check mark indicates that you have read, understand, and agree to the information provided in each of the policies and procedures.I have read, understand and agree to the Medication Management Agreement.I have read, understand and agree to the Medication Management Agreement.* I have read, understand agree to the Electronic Communication Policy.I have read, understand agree to the Electronic Communication Policy.* I have read, understand and agree to the Client Rights & Responsibilities.I have read, understand and agree to the Client Rights & Responsibilities.* I have read, understand and agree to the Notice of Privacy Practices.I have read, understand and agree to the Notice of Privacy Practices.* I have read, understand and agree to the Financial Obligation Policy.I have read, understand and agree to the Financial Obligation Policy.* I have read, understand and agree to the Distance Counseling Procedures.I have read, understand and agree to the Distance Counseling Procedures.* I have read and understand the above information, have had an opportunity to ask questions about this information, and I consent to behavioral health treatment through the Cognitive Behavior Institute as outlined above. If applicable, I also attest that I am the legal guardian and have the right to consent for the treatment of this minor.Signature of Legal Guardian (if client under age 14)Date Print NameSignature of ClientDate Print NameSignature of Additional Client(s) (if appropriate)Date Print Name This iframe contains the logic required to handle Ajax powered Gravity Forms. Scroll Up
