Therapy / Counseling, Psychological Assessment, Other

Patient Information:

Patient's Name(Required)
Patient's Address(Required)

Parent / Guardian Information:

Parent(s)/​Guardian(s) Name:(Required)
First Name
Last Name
 
Address *if different*
Are you the legal guardian?(Required)

Insurance Information:

Secondary Insurance?
I authorize payment of medical benefits to the undersigned physician or supplier Behavioral Solutions, LLC for mental health services:
Clear Signature
I authorize the release of any medical or other information necessary to process this claim:
Clear Signature
Confidentiality: I understand that I may have access to private patient information while visiting Behavioral Solutions, which operates within the Family First Center for Autism building. I agree to keep all patient information confidential and will not discuss, share, or disclose it to anyone. I understand that HIPAA and state laws protect this information.
Clear Signature
Video & Audio Acknowledgement: I understand and acknowledge that Family First Center for Autism uses video and audio surveillance for office security and safety purposes. Direct sessions with Behavioral Solutions psychologists will not be video monitored. I understand that Behavioral Solutions cannot control or limit Family First's audio or video surveillance within the building. I understand that my privacy and HIPAA rights will be respected and protected while I am in the building. Behavioral Solutions will maintain the confidentiality of my information in accordance with applicable privacy laws.
Clear Signature