DOMINION BEHAVIORAL HEALTHCARE
Adult Intake Forms
Patient Demographics
Patient’s Name: __________________________________________ Appointment Date: _____________
Date of Birth: __________________ Age: _________ Sex: Male/ Female SSN:__________________
Address: _____________________________________________________________________________
City: _____________________________ State: ______________________ Zip: ___________________
Marital Status: (Circle One)
Single
Married
Divorced
Separated
Widowed
Home Phone: ______________________________ Cell Phone: ___________________________
Work Phone: ________________________________ May we contact you at work?
Yes
No
Employer: _________________________________________________________________________
Please select the best day time phone number: (Circle One)
Home
Would you like to receive appointment reminders by phone?
Yes
Cell
Work
No
Please select which phone number you would like to be contacted for appointment reminders:
(Circle One) Home
Cell
Work
To receive appointment reminders by email, please provide this information:
Email Address: ___________________________________________________________________
Emergency Contact Information
Emergency Contact Name: _____________________________________ Relationship: ______________
Emergency Contact Phone Number: ____________________________________
Insurance Information
Primary Insurance Company: _____________________________________________________________
Subscriber’s Name: ________________________________ Subscriber's Date of Birth: ______________
Subscriber’s Sex: Male/Female
Relationship to Patient: __________________________________
Insurance Card Member ID#:____________________________ Group#: _________________________
Subscriber’s Employer Name: ____________________________________________________________
Secondary Insurance Company: ___________________________________________________________
1
Revision Date: March 2016
Subscriber’s Name: _________________________________ Subscriber’s Date of Birth: _____________
Insurance Card Member ID#: ___________________________ Group#: __________________________
Employee Assistance Program (EAP)
Are these visits covered by an Employee Assistance Program (EAP) benefits?
Yes
No
If yes, please provide the following information:
Name of EAP program: _________________________________________________________________
Contact Number: __________________________ Authorization #: ______________________________
Allotted Number of Visits: _________________ EAP Start Date: _______________________________
Medical Information
Primary Care Physician: ____________________________ Phone Number: _______________________
Address/ Location: _____________________________________________________________________
Please list all Current Medications:
Medications
Dosage
Prescribing Physician
___________________________
_____________________
__________________________
___________________________
_____________________
__________________________
___________________________
_____________________
__________________________
___________________________
_____________________
__________________________
Have you received counseling, psychological, or psychiatric services in the past?
Yes
No
If yes, please provide the Professional’s Name and Dates of treatment:
Name of Professional
Services Began
Services Ended
______________________________
_______________
_________________
______________________________
_______________
_________________
Have you ever been hospitalized for mental health reasons?
If yes, When? ________________________________
Yes
No
Where? ________________________________
Length of Stay: _______________________________
Who referred you to our practice? _________________________________________________________
2
Revision Date: March 2016
Please explain briefly your reason/reasons for seeking help at this time:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please provide any additional information that you believe may be helpful:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please check any of these that have been a problem recently?
_____Anxiety/Excessive Worrying
_____Panic Attacks
_____Extreme Fear
_____Sadness
_____Depressive Mood
_____Suicidal Thoughts
_____Sleep Problems
_____Lack of Energy/Motivation
_____Anger Problems/Irritable Mood
_____Lack of Self-Control
Please Explain: _____________________________
_____Excessive Energy
_____ Trauma
_____Gender Concerns
_____Eating Problem/Eating Disorders
_____Undue Stress
Please explain: _____________________________
_____Concentration Problems
_____Memory Problems
_____Work/Career Problems
_____Educational Problems
_____Alcohol Use/Abuse
_____Other Substance Use/Abuse
_____Legal Problems
_____Problems with Children
_____Marital/Relationship Problems
_____Domestic Violence
_____Separation/Divorce
_____Grief/Loss
_____Financial Problems
_____Health Problems/Major Illness
_____Other:____________________
Lifestyle Questions
Nutrition: Do you eat a healthy, well balanced diet most of the time?
Yes
No
Would you like to improve your diet?
Yes No
Currently Dieting?
Yes
No
Exercise: Do you exercise regularly? Yes No
If yes, approximately how many days per week do you exercise __________
Sleep: Insomnia?
Yes
No
Sleep Too Much? Yes
No
Smoking: Do you smoke tobacco?
Yes
No
If yes, are you interested in stopping? Yes
No
Social Network: Do you engage in positive daily social interactions? Yes No
Do you have anyone you feel comfortable confiding in?
Yes
No
Hobbies: Do you have any hobbies you enjoy participating in on a regular basis?
Yes
No
Stress Management: Do you feel under stress?
Yes
No
If yes, please specify ways in which you reduce stress: __________________________________
Would you like to learn new/additional ways of reducing stress?
Yes
No
3
Revision Date: March 2016
DOMINION BEHAVIORAL HEALTHCARE
Consent for Treatment
I, the undersigned, do voluntarily consent to psychiatric/behavioral health assessment and/or treatment for
myself.
By signing below, I authorize Dominion Behavioral Healthcare to provide psychiatric and/or behavioral
health assessment and exams, treatment, and/or diagnostic procedures which now, or during the course of
my treatment, become advisable. I understand that the purpose, potential risks and benefits, and
alternatives to any treatment, as well as the risks of not having treatment, will be explained to me upon
my request, and that I can always decline treatment.
I understand that while my treatment will be designed to help me, there is no guarantee of a successful
outcome.
Psychotherapy involves risks, such as but not limited to, the development or worsening of emotions such
as anxiety, sadness and anger. I understand that this is a normal response to working through life
experiences and that these reactions should be discussed with my therapist or physician.
Treatment with Medication also has certain risks, varying with the type of medication prescribed, which
will be explained to me. I know that taking a medication of any kind always carries the risk of a
potentially fatal allergic reaction. I understand that it is my responsibility to make my physician aware of
any health conditions that I have or that develop over the course of treatment, and to make my physician
aware of any other medications, including over-the-counter medications or herbal supplements that I am
taking. I also understand that discontinuation of medication should be discussed in advance with my
physician.
I understand that it is my responsibility to inform my physician or therapist if I feel worse in response to
any treatment provided, including but not limited to, the development or worsening of suicidal ideation,
depression, agitation, anxiety, insomnia, irritability or mania, especially if these reactions are new, severe,
or abrupt in onset.
________________________
Print Patient Name
_____________________________
Signature of Patient
______________
Date
4
Revision Date: March 2016
Consent for Coordination of Care
PATIENT NAME: ___________________________ DATE OF BIRTH: __________
PRIMARY CARE PHYSICIAN: ___________________________________________
PSYCHIATRIST: _______________________________________________________
THERAPIST/COUNSELOR: ______________________________________________
___ I DO give permission for my treating provider to share information with the above
named provider. I understand that this release shall be valid for 90 days following mine
or my child’s last date of treatment. I understand that I may revoke this authorization at
any time during the course of my treatment or my child’s treatment.
___I DO NOT give permission for my provider to share information with the above
named provider.
______________________________
Signature of Patient
_________________
Date
Below for office use only
Date: ____________________
Dear: __________________________________________:
In an effort to coordinate care, we are writing to inform you that the above named
individual was seen by: _____________________________________ for an initial
assessment/treatment. The initial assessment reveals:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Any medications provided are listed below:
______________________________________________
______________________________________________
_______________________________________________
Sincerely,
__________________________________
5
Revision Date: March 2016
DOMINION BEHAVIORAL HEALTHCARE
Authorization to Release Information
In accordance with HIPAA privacy laws, a signed consent form is required to release information in any
form about your care. This authorization allows us to communicate when needed or requested regarding
scheduling, insurance or billing information, as well as routine or emergency contact. This authorization
may be rescinded or amended at any time that you choose.
Please use the space below to identify any persons with whom you may want us to have contact.
I, __________________________________, certify that I am 18 years old or older and give
permission for Dominion Behavioral Healthcare to communicate with the following persons about
my treatment:
Name
Relationship
Phone
1)___________________________________________________________________________
2)___________________________________________________________________________
3)___________________________________________________________________________
4)___________________________________________________________________________
___________
Please Check
No Authorization to Release Information to any Nonprofessionals
____________________________
Print Patient’s Name
_____________________________
Signature of Patient
____________
Date
6
Revision Date: March 2016
DOMINION BEHAVIORAL HEALTHCARE
OFFICE POLICIES AND FINANCIAL AGREEMENT
Please read this agreement carefully and sign on the last page.

Our clinicians participate with many insurance companies and in most cases we will bill your
insurance company for you. However, you are ultimately responsible for the payment of all
charges on your account even if your insurance company denies the claim or otherwise refuses to
reimburse the charges. To avoid any unexpected charges, we ask that you verify your coverage
and note any restrictions or limitations prior to beginning treatment.

Preauthorization: It is your responsibility to obtain any initial preauthorization required by your
insurance company prior to beginning treatment. Failure to do so by the end of business on the
day of your initial appointment may result in denial of coverage and leave you responsible for
payment in full for the initial appointment, regardless of any coverage you may have been entitled
to by obtaining a required preauthorization.

Payment is due at the time of service for your portion of the bill. This includes any portion of
the bill that is not covered by your insurance company. Fees not covered by insurance include,
but are not limited to, copayments or co-insurance, deductible, fees for any services not deemed
medically necessary by your insurance, charges for telephone consultation, school meetings,
educational testing and services, most court-ordered services, letter and report writing, the
completion of forms, depositions/court appearances, charges for missed appointments, and
charges for prescriptions refills outside of your office visits.

Returned checks: There is a $25.00 fee for returned checks.

Responsible Parties: For our billing purposes, the person signing this form and consenting to
treatment WILL be considered the responsible party. If another person is legally responsible for
medical bills not covered by insurance (for example, in the case of divorced parents, your child’s
other parent) we will provide you with necessary documentation you need in order to obtain
reimbursement from that person. We will not bill that party directly.

Changes in Insurance Coverage: It is your responsibility to notify both your clinician and the
billing office of any changes in your insurance and to provide us with a copy of any new
insurance card (s). It is also your responsibility to contact your insurance company to obtain any
preauthorization that may be required by your new insurance policy. Failure to do so may result
in denial of coverage and leave your responsible for payment in full for all charges, including fees
that would have been covered by your insurance had you obtained authorization and/or notified
us immediately of the change in your insurance.

Cancellation Policy: You will be charged a $75.00 fee for missed appointments and
appointments cancelled with less than 24-hour notice, Monday appointments must be cancelled
by the appointment time on the preceding Friday in order to avoid this charge. This fee is not
covered by insurance and will be your responsibility.
7
Revision Date: March 2016
DOMINION BEHAVIORAL HEALTHCARE
OFFICE POLICIES AND FINANCIAL AGREEMENT-Continued

Charge for prescription refills: Prescriptions are generally written at the time of your
appointment with enough refills to cover the time that your psychiatrist is comfortable allowing
before seeing you again, so additional refills between visits should not be necessary. If a refill is
required between visits, you will be charged a $20.00 fee for the time taken to review the chart
and prepare/call-in the prescription. This fee is not covered by insurance and is your
responsibility. Patient must call in for refill requests; we do not provide refills in response to
pharmacy calls/faxes.

Telephone calls: Please save routine clinical updates and questions for your scheduled
appointment. While there is not charge for brief calls, non-emergency calls lasting more than 5
minute or frequent non-emergency calls will be billed at a rate of $120.00 per hour, with a
minimum charge of $30.00.

Emergencies: Your clinician or an on-call clinician for DBH is available at all times for true
clinician emergencies by calling the office during normal business hours and by calling the DBH
answering service at (804) 346-5701 outside of normal business hours. If at any time you believe
that you are unable to wait for a return call from your clinician or the on-call clinician you should
call 911 or go to your nearest emergency room.

Court Testimony: The fee for any requested deposition or court testimony, regardless of whether
the clinician is served a subpoena or requested to testify by one of the parties is $250.00 per hour
with a minimum charge of $1000.00 (for up to 4 hours). This includes time needed for
preparation and travel. Additional fees may be assessed if travel outside of the immediate area is
required.

Payment for court testimony: Payment in full for depositions and court testimony is required 5
business days in advance of the scheduled hearing. In the event that a deposition or hearing is
cancelled less than 3 business days in advance, a charge of $250.00 will be assessed. Depositions
or hearing cancelled with less than 24 hour notice will be assessed the full fee. Responsibility for
the payment in full for any requested court testimony is ultimately yours, regardless of which
party may have issued a subpoena. Fees for depositions and court testimony are not covered by
insurance.

Past due accounts: Patients with large past-due balances will have their accounts reviewed and
may not be eligible for further services. Please keep your account current and up-to-date to avoid
any disruption in treatment. If you are having difficulty paying your bill, please discuss this with
your clinician and/or the billing department. We may be able to make arrangements for a payment
plan or refer you to an agency that can provide treatment at a reduced cost. If your account is not
paid in a reasonable amount of time, it will be turned over to a collection agency and you will be
charged a collection fee of $50.00 to cover the additional costs accrued in this process.

Closed charts: If you have not had any appointments for 12 months, we will consider you to have
terminated treatment and your chart will be closed. You may, of course, return to treatment as a
new patient.
8
Revision Date: March 2016
DOMINION BEHAVIORAL HEALTHCARE
FINANCIAL AGREEMENT
PLEASE READ CAREFULLY
Summary of Fees
Effective January 1, 2016
Types of Service
Initial Evaluation (Therapist/Counselors)
Initial Evaluation (Psychiatrist)
Psychiatric Follow-Up
Prescription refills between appointments
Individual Therapy (60 min.)
Individual Therapy (45 min.)
Family Therapy (45 min.)
Group Therapy (60-75 min.)
Specialized Evaluations
Bariatric Surgery Evaluation
Bariatric Surgery Report Writing
Couples Assessment & Feedback
Myers-Briggs Personality Testing & Feedback
Psychological or Educational Testing
(includes time for administration, scoring, interpretation
and report writing)
School Observation/Meeting (includes time for travel)
Deposition/Court Testimony (includes travel and
preparation) TO BE PAID IN ADVANCE
No Show or Late Cancellation Fee
(Must be paid prior to next scheduled appointment)
Letter or Physician statement
Associated Fees
$150
$250
$125-$250
$20
$150
$125
$150
$70
$150
$75
$200-$250
$150
$150/hour
$150/hour
$250/hour
Min. $1000
$75
$120/hour
Min. $70
$120/hour
Min. $30
$120/hour
Min. $70
$50
Telephone Calls (more than 5 minutes and nonemergency)
Completion of Health/Disability Forms
Returned Check Fee
By signing below, I acknowledge that I have read and understand this financial agreement.
I hereby request that payment of authorized insurance benefits (including Medicare), if I am a services
beneficiary, be made on my behalf to Dominion Behavioral Healthcare for any services provided to me
by DBH. I authorize the release of any medical or other information by DBH necessary to process my
claims. I understand that I am financially responsible for any charges that are not covered by my
insurance.
Responsible Party Signature: ____________________________________ Date___________________
Responsible Party Name (Print): ________________________________________________________
Patient Name:___________________________________
Date of Birth: ______________________
Relationship to Patient: ________________________________
Responsible Party Address: _____________________________________________________________
9
Revision Date: March 2016
DOMINION BEHAVIORAL HEALTHCARE
VIRGINIA NOTICE FORM
Notice of mental health professionals’ practices and policies in compliance with HIPAA (Health
Insurance Portability and Accountability Act) to protect the privacy of your health information.
Please read the following information carefully and sign the last page.
I understand that as part of my mental health care, Dominion Behavioral Healthcare originated and will
maintain paper and/or electronic records describing treatment, testing results and forms, correspondence
and insurance information. Except when required by law, this information cannot be disclosed without my
written consent. I may revoke any authorization for disclosure at any time except if the authorization was
obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to
contest the claim under the policy.
I understand that information from the medical record may be disclosed without obtained consent for the
following conditions:
1. Child Abuse- State law requires that your clinician disclose information regarding suspected
harmful actions or neglect toward children.
2. Adult or Domestic Abuse- State law requires your clinician to report and provides information of
there is suspicion of adult abuse, neglect or exploitation.
3. Health Oversight- Regulating Boards have the power to subpoena relevant records if a clinician is
the focus of the inquiry.
4. Judicial or Administrative Proceedings- If you are involved in a legal proceeding and your mental
health records are requested, the information will not be released except if it is requested by
subpoena. If you desire to quash (block) the subpoena, then your record will be provided to the
clerk of the court in a sealed envelope so that the court can determine whether the records should
be released.
5. Serious Threat of Health or Safety- If you have communicated directly to your clinician that you
have a specific and immediate plan to cause serious harm or death to an identifiable person and if
your clinician has sufficient evidence based on your conversations, history and treatment to
believe this threat is real, then the law requires the clinician to take steps to protect the third party.
Either the third party can be warned, or their parents warned if they are under 18, or the law
enforcement officer may be contacted.
6. Serious Threat to Yourself- If you have communicated directly to your clinician that you have
specific and immediate plans to cause serious harm or death to yourself and if your clinician has
sufficient evidence based in your conversations, history and treatment to believe this threat is real,
then the law requires the clinician to take steps to protect you be either contacting a significant
other or admitting treatment facility.
7. Worker’s Compensation- If you file a worker’s compensation claim, the law requires that relevant
mental health information be submitted to your employer, insurer or a certified rehabilitation
provider.
10
Revision Date: March 2016
DOMINION BEHAVIORAL HEALTHCARE
VIRGINIA NOTICE FORM- Continued
I understand that I have the following rights:
1. I have the right to request restriction on certain uses and disclosures of my mental health
information. Your clinician may or may not be required to agree upon these restrictions.
2. I have the right to request and receive confidential communication by alternative means and at
alternative locations (e.g. fax or e-mail).
3. I have the right to inspect and obtain a copy of my mental health record and billing records. The
access to this information may be denied under some circumstances. You are entitled to a
discussion with your clinician regarding the reasons limiting access to your records.
4. I have the right to request an amendment to my records, but this request can be denies by your
clinician.
I understand that my treating clinician is required by law to maintain privacy of my mental health record
and to provide me with notice of their legal duties and privacy practices with respect to my mental health
record. The treating clinician has the right to change those privacy policies and practices with notification
to you in writing.
I understand that I have the right to disagree with decision made and I can make a formal complaint to a
Dominion Behavioral Healthcare Privacy Officer at (804) 270-1124. A written complaint can be made to
the Secretary of the U.S. Department of Health and Human Services.
I understand that this notice is in effect beginning June 1, 2005. If there are any changes to this notice I
am still in treatment at DBH then I will be notified in person and writing about such changes.
I understand that my clinician may need to contact me. I agree to the following forms of communication,
knowing that the clinician will leave their name and information about my appointments.
Please circle all to which you agree:
Voice Mail:
Home
Work
Cell
E-Mail:
Home
Work
Cell
Verbal Message:
Home
Work
Cell
I have read and understand this HIPAA policy. Please sign and enter today’s date.
__________________________________
Signature of Patient
_______________
Date
11
Revision Date: March 2016