Behavioral Health - Current HVH patient Forms

Hello!

Thank you for scheduling your first visit with Behavioral Health at HorizonView Health! This form is for patients who have already been seen in our clinic but are having their first visit with Behavioral/mental health. If you have any questions please call us at 253-268-3345

Thank you so much!

HorizonView Health staff

Patient Legal Name*

First NameLast Name

Patient Date of Birth*

Date

How often have you been bothered by any of the following:*

	Not at all	Several Days	Over half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling/staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself or that you are a failure, or let yourself or your family down
7.concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking slowly that others have noticed. Or the opposite, restless/fidgety more than usual
9. Thoughts that you would be better off dead or of hurting yourself in some way

If you checked off any problems on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*

Not difficult at allSomewhat difficultVery DifficultExtremely Difficult

Do you have thoughts of death or suicide?*

YesNo

How often have you been bothered by any of the following?*

	Not at all	Several days	Over half the days	Nearly every day
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worry
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

If you checked off any problems on this questionnaire so far, how difficult have these problems made it for you to do work, take care of things at home, or get along with other people?*

Not difficult at allSomewhat difficultVery difficultExtremely difficult

While you were growing up, during your first 18 years of life:*

	Yes	No
1. Did a parent or other adult in your house often swear at you, insult you, put you down, or humiliate you? OR Act in a way that made you afraid that you might be physically hurt?
2. Did a parent or other adult in your house often push, grab, slap or throw something at you? OR Ever hit you so hard that you had marks, bruises, or were injured?
3. Did any adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? OR Did anyone attempt to have oral, anal or vaginal intercourse with you?
4. Did you often feel like no one in your family loved you or thought you were important or special? OR Did you feel like your family members didn't look out for each other, didn't feel close to each other, and didn't support each other?
5. Did you often feel like you didn't have enough to eat, had to wear dirty clothes, or had no one to protect you? OR Were your parents ever too drunk or high to take care of you or take you to the doctor if you needed to go?
6. Were your parents ever separated or divorced?
7. Was your mother or step-mother often pushed, grabbed, slapped, or had something thrown at her? OR Sometiems, often or very often kicked, bitten hit with a fist, or hit with something hard? OR Ever repeatedly hit at least a few minutes or threatened with a gun or knife?
8. Did you live with anyone who was a problem drinker or alcoholic or used drugs on a regular basis?
9. Was anyone in your household depressed, mentally ill, or ever talked about or tried to commit suicide?
10. Did anyone in your household ever go to prison?

CONSENT: I consent to medical services discussed and ordered by a physician and given by HorizonView Health. HorizonView Health may share health information about me, my guardian(s) or parent(s) to physicians and providers who treat me.

FINANCIAL AGREEMENT: I, the patient or guarantor, certify that the information provided is true to the best of my knowledge. I accept responsibility for the medical charges incurred by the patient and agree to pay all bills at the time of service unless arrangements are made. I authorize HorizonView Health, to release any information to process insurance claims. I also authorize my insurance claim to be paid directly to HorizonView Health.

RELEASE OF INFORMATION: I permit HorizonView Health to release information needed for eligibility and benefits, and to process claims for payments. I agree that all insurance payments be paid directly to HorizonView Health for services rendered.

By my signature below, I agree to the Consent of Treatment & have received the Notice of Privacy Practices of HorizonView Health.

Signature

Clear

Date

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and Privacy Practices with respect to PHI. We are required to abide by the terms of the Notice of Privacy Practices. We reserve the right to change the terms of the Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will make available a revised Notice of Privacy Practices upon request.

Signature

Clear

Date

This policy has been established to provide the highest level of counseling service to all our clients. It has been proven that consistent attendance provides for the greatest opportunity for success.

By providing us with enough notice of cancellation, we may be able to accommodate other clients with your appointment time. Please provide our office with a 24-hour notice to change or cancel an appointment.

Clients who do not provide a 24-hour notice to cancel or change a scheduled appointment will be responsible for a $75.00 late cancellation fee. This charge cannot be billed to insurance.

Clients that do not contact us and do not attend their scheduled appointments are considered no shows. A $75.00 no show fee will be charged. This charge cannot be billed to insurance. If you do no-show, the $75.00 will automatically be charged to the credit card on file.

When late cancellations and/or no shows become excessive, the therapist then has the right to terminate the relationship. Two no shows and/or late cancellations over the year would be considered excessive. This policy is effective January 1st, 2021. We do understand that emergencies arise and that it may not be possible to give such a notice. Exceptions to the late cancellation and no-show policy with be determined by our office.

I have read and understand this policy.

Signature

Clear

Date

A Telehealth service means that my visit with a practitioner at the distant site will happen by using special audiovisual equipment (Zoom). This consent is valid for all follow-up Telehealth services with HorizonView Health.

I understand that:

I can decline the Telehealth service at any time without affecting my right to future care or treatment.
If I decline the Telehealth services, the alternative option would be in-person services.
The same confidentiality protections that apply to my other medical care also apply to the Telehealth services.
I will have access to all medical information resulting from the Telehealth service as provided by law.
The information from the Telehealth service (images that can be identified as mine or other medical information from the Telehealth service) cannot be released to researchers or anyone else without my additional written consent.
I understand that my insurance will be billed for the telehealth services, and that I will be billed for what my insurance does not cover. By signing this consent, I am giving permission to release information to my insurance company or third-party payor for billing purposes.
I have read this document carefully, and my questions have been answered to my satisfaction. I understand this consent is valiid for all telehealth follow-ups at HorizonView Health.

Signature

Clear

Date

Parent/Guardian (if not signed by patient)

First NameLast Name

Behavioral Health Forms - (for current HVH patients)

Patient Health Questionnaire

Adverse Childhood Experience (ACE) Questionnaire

Consent of Treatment

Notice of Privacy Practices Acknowledgement

THERAPY LATE CANCELLATION AND NO-SHOW POLICY

Telehealth Consent Form