ASTRA BH SCHOOL BASED PATIENT REGISTRATON

POLICY ACKNOWLEDGEMENTS AND CONSENTS

ACKNOWLEDGEMENT OF RECEIPT OF FORMS (ATTACHED ABOVE)*

	INITIAL BELOW
INFORMED TELEHEALTH CONSENT
AUTHORIZATION FOR OUTPATIENT TREATMENT
CONSENT TO BILL PATIENT INSURANCE
CLIENT PAYMENT PROGRAMS & FEE AGREEMENT
CONFIDENTIALITY OF CLIENT RECORDS
NOTICE OF CLIENT RIGHTS
VIDEO MONITORING PRACTICES
PATIENT RESPONSIBILITIES
LATE CANCELATION/ NO SHOW POLICY
NOTICE OF PRIVACY PRACTICES
YOUR INDIVIDUAL RIGHTS UNDER HIPAA

My initial by the name of each individually listed document and my signature affixed below affirms that I have received, read, fully understand, and agree to the contents of each document and, should I have any questions, I will ask a staff member of Astra Behavioral Health, LLC.

My signature affixed below acknowledges I wish to have treatment given to me, my child, or my ward by Astra Behavioral Health, LLC. Also, my signature affirms I have been informed of the treatment and procedures necessary, which will be performed by a psychiatrist, psychiatric nurse practitioner, therapist, and/or assisted by other staff members of Astra Behavioral Health, LLC; and my authorization to receive such treatment and procedures is hereby granted.
SIGNATURE OF PATIENT OR PATIENT REPRESENTATIVE*

Clear
TODAYS DATE*

MonthDayYear
Date

PAYMENT AGREEMENT - SCHOOL BASED SERVICES

NOTE: PATIENTS WITH MEDICAID INSURANCE PLANS ARE NOT REQUIRED TO FILL OUT THIS FORM
Dear Parent or Guardian,

Astra Behavioral Health has partnered with your child’s school to offer therapy services to your child while in school; if indicated. To take advantage of this service, Astra is implementing a process for you to be aware of when your child is seen by a therapist, so that you may be able to have the input needed for therapy services to be successful. This will, also, allow you to plan for payment of therapy services and that your child may be seen as often as you, the therapist, and child have determined is necessary.

Our billing office will reach out to you to determine your copayments, deductibles, and any out-of-pocket expenses within 30 days of the first appointment.

I, First Name Last Name parent/guardian of,Child's First NameChild's Last Name , give Astra Behavioral Health permission to see my child # of days days per month. I understand that my copayment and/or deductibles will apply to these visits. Therefore, I authorize Astra Behavioral Health to keep my signature on file and charge my Visa, Mastercard, Discover or American Express for copayments and/or deductibles which may be required by my insurance to receive mental health services provided by Astra Behavioral Health for the child named above.
CARDHOLDER'S NAME
As shown on card
CARD NUMBER
####-####-####-####
EXP. DATE
CVV
3-digit Number
BILLING ADDRESS

Street Address

Street Address Line 2

CityState

Zip Code
PARENT/GUARDIAN'S NAME:

First NameLast Name
TODAY'S DATE

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE:

Clear
WITNESS SIGNATURE

Clear
Should be Empty:

	MEDICATION	DOSAGE
Medication 1
Medication 2
Medication 3
Medication 4

	YES	NO
Are you in need of resources, such as housing, clothing, education, food, and more?
Do you need assistance with employment?
Do you have transportation issues?
Do you need assistance with benefits, such as food stamps, SSI, SSDI, KTAP, or insurance?
Would you like help with finding community activities for yourself and your family?
Have you experienced alcohol or drug problems within the past year?
Are you having trouble accessing medical care?
Are you feeling overwhelmed?

	YES	NO
Has your child ever engaged in self-injurious behavior, patterns of reckless decisions, had an eating disorder or threated or attempted suicide?
Does your child have trouble making friends or communicating with children their own age?
Is there a current or previous court or child protective services involvement regarding this child?
Are you struggling to manage your child's behavior at home?
Is your child having behavior issues at school or struggling academically (failing classes)?
Does your child engage in dangerous behaviors (violence/fighting, damaging property, leaving home without permission, fire-setting, etc?
Does you child follow rules/laws at home or school?
To the best of your knowledge, has your child ever used drugs, alcohol, tobacco products or other illegal products?
Has your child has a psychiatric hospitalization within the past year?
Do you have any other concerns regarding your child that are not listed above?

SCHOOL BASED/DAY TREAMENT REGISTRATION FORMS

PATIENT DEMOGRAPHICS

HEALTH INSURANCE INFORMATION

CURRENTLY PRESCRIBED MEDICATIONS

EMERGENCY CONTACT INFORMATION

RESOURCES

IF PATIENT IS A MINOR

POLICY ACKNOWLEDGEMENTS AND CONSENTS

PAYMENT AGREEMENT - SCHOOL BASED SERVICES