www.communitybehavioralhealth.net
Intake Line: (844) 224-5264 x104
Below you will find our intake
forms. Please print these
documents, answer all relevant
questions, and bring the
COMPLETED FORMS to your
local CBH clinic along with your
ID and Insurance Card. Delays in
receiving all documentation may
delay your enrollment.
107 East Market St
Snow Hill, MD 21863
426 Dorchester Ave
Cambridge, MD 21613
30519 Prince William Street
Princess Anne, MD 21853
106 Lee St
Salisbury, MD 21804
8614 Ocean Gtwy
Easton, MD 21601
809, 811, 817 & 821 Eastern Shore Drive
Salisbury, MD 21804
202 Coursevall Drive #107
Centreville, MD 21617
10774 & 10810 Hickory Ridge Road
Columbia, MD 21044
300 Scheeler Rd
Chestertown, MD 21620
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COMMUNITY BEHAVIORAL HEALTH
426 Dorchester Avenue, Cambridge, MD 21613
202 Coursevall Drive Unit 107, Centreville, MD 21617
300 Scheeler Road, Chestertown, MD 21620
10774 Hickory Ridge Road, Columbia, MD 21044
8614 Ocean Gateway, Easton, MD 21601
30519 Prince William Street, Princess Anne, MD 21853
809 + 821 Eastern Shore Drive, Salisbury, MD 21804
107 East Market Street, Snow Hill, MD 21863
www. communitybehavioralhealth.net
Phone: (844) 224-5264 Fax: (888) 509-0010
CONSENT FOR TREATMENT AT
COMMUNITY BEHAVIORAL
HEALTH
NOTE: Please sign and complete the highlighted questions at the bottom of this document before saving
and sending it for review.
Name:______________________________________________
Date: _______________________________________________
Phone Number: ________________________________________
Email Address: _________________________________________
A. GENERAL CONSENT FOR TREATMENT
I voluntarily consent (or I voluntarily provide for my child, consent) to treatment and/or related services by
Community Behavioral Health which may be advised and recommended by the attending physician. I
understand that in the event of a medical or psychiatric emergency which may be life-threatening, that it
may become necessary for Community Behavioral Health to render such emergency treatment and/or
transfer myself or my child to a hospital for treatment.
I understand that no promises have been made to me as to the results of treatment or of any procedures
provided by this organization.
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I am aware that I may stop my treatment with Community Behavioral Health at any time. The only thing I
will still be responsible for is paying for the services I have already received. I understand that I may lose
other services or may have to deal with other problems if I stop treatment. (For example, if my treatment
has been court-ordered, I will have to answer to the court).
I know that I must call to cancel an appointment at least 24 hours before the appointment time. If I do not
cancel or do not show up, I may be charged $25.00 for that appointment. If I repeatedly miss
appointments without notice, I am aware this may lead to my discharge from Community Behavioral
Health.
I am aware that an agent of my insurance company or other third-party payer may be given information
about the type(s), cost(s), date(s) and providers of any services or treatments I receive. I understand that
if payment for the services I receive here is not made, Community Behavioral Health may stop treatment.
I give permission for Community Behavioral Health to use an electronic medical record and an electronic
billing system per HIPAA and COMAR regulations. These sites are both state and federally approved
entities for medical record information and maintain confidentiality.
I give permission to utilize my electronic signature for the purpose of treatment planning and any other
documentation as it pertains to patient care. I understand that all treatment planning documentation will
be reviewed with me and I am entitled to a copy of this plan. I acknowledge that I have received a copy of
Community Behavioral Health Notice of Privacy Practices which summarizes the ways my health
information may be used and disclosed by Community Behavioral Health and states my rights with
respect to my Protected Health Information (PHI).
I understand that Community Behavioral Health has the right to revise these information practices and to
amend the Notice of Privacy Practices. I have been informed that in the event Community Behavioral
Health changes this Notice, a revised Notice will be posted in the office waiting room and that I may
obtain a current Notice of Privacy Practices at any time from the front desk.
B. PATIENT BILL OF RIGHTS
Regardless of race, religion, sex, gender identity, ethnicity, age or handicap, each patient at Community
Behavioral Health has the following rights:
1. Receive appropriate humane treatment and services that restrict the individual only to the extent
necessary and consistent with the individual's treatment needs and applicable legal requirements.
2. Be free from restraints and seclusion except in an emergency where the individual presents
danger to the life and safety of the individual or others; or to present serious disruption of the
therapeutic environment.
3. To expect reasonable safety insofar as Community Behavioral Health’s practices and
environment are concerned. This right includes, but is not limited to the right to be free or
protected from any kind of abuse at Community Behavioral Health including mental, physical,
sexual, and corporate.
4. Subject to the applicable provisions of law, have access to the individual's medical records and
have medical records kept confidential.
5. Receive treatment in accordance with an individual treatment plan; participate in the development
and periodic updating of the treatment plan, and be appropriate terms and language of:
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10.
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25.
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The content and objectives of the plan
Nature and significant possible adverse effects of recommended treatments
The name, title, and role of the persons responsible for carrying out the treatment and
When appropriate, alternative treatments for mental health services that are available
Refuse to participate as a subject in physically intrusive research conducted at the facility
Choose to refuse medication used for the treatment of a mental disorder except when:
The medication is ordered by a physician in an emergency where the individual presents a
danger to life or safety of the individual or others
The right, prior to admission, to an explanation in terms and language that the individual can
understand, of the charges and fees that the individual will be required to pay.
To receive positive recognition, to be treated with warmth and caring, and to be spoken to and
treated in an age-appropriate manner.
To know the name, title, and role of qualified professionals on your team, who are credentialed
and/or trained to provide the perceived care, treatment, and services for which they are
responsible.
To have your medical record read only by other individuals on your written authorization or that of
your legally authorized representative, or a court order requiring the release of information, or for
disclosure of suicidal or homicidal thoughts in order to maintain your safety, or when suspicions of
child abuse requires the mental health professional to report to local authorities.
To receive an education about your diagnosis, treatment, and aftercare/discharge plan. This
includes the option to discuss with the treatment team any aspect of care or treatment, to actively
participate in the planning of care and treatment, and resolve dilemmas, provided it is not legally
adverse to you or in the opinion of your therapist, it would not be medically advisable for you to
receive.
To confidentiality and privacy regarding communications between yourself and staff, and to refuse
to talk with or see anyone not officially connected with Community Behavioral Health, including
visitors, or persons officially connected with the agency, but not directly involved in your care.
To refuse to be photographed by an employee, visitor, or client except as may be required for
issuance of a client identification card.
Community Behavioral Health respects the rights of our clients. While the staff will endeavor to
ensure that the rights as defined above are protected, the client has the responsibility to inform
the Community Behavioral Health staff as soon as possible if they believe any of these rights
have been or may be violated. This can be done at any time by discussing such concerns with
members of the treatment team.
To the most appropriate care and treatment available and receive sufficient information regarding
treatments in order to make informed decisions regarding your goals and objectives, effects and
possible side effects of medication, and to receive appropriate and timely medical treatment for
illness, injury or disabilities, in the least restrictive environment, regardless of sex, religion, color,
national origin, source of payment for care, or natures of the severity of disabling condition if you
meet the admission criteria.
To explanations regarding clinical fees prior to admission.
To request the opinion of a consultant at your expense.
To request to leave Community Behavioral Health prior to the termination of treatment to the
extent permitted by law.
To refuse specific medications or treatment procedures provided the legal responsibilities of the
agency to provide time and appropriate care and treatment are not compromised.
To initiate compliance or grievance procedures and the appropriate means of requesting a
hearing review of the grievance.
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27. To personal possessions and property not deemed contraband and in accordance with applicable
Community Behavioral Health policies and state laws.
28. To wear appropriate personal clothing while at Community Behavioral Health appointments or
on-site at the facility.
29. To refuse to participate in physically intrusive research. Community Behavioral Health respects
the rights of the family of origin, and foster families.
While the staff will endeavor to ensure that the rights as defined above are protected, the client has the
responsibility to inform the Community Behavioral Health staff as soon as possible if they believe any of
these rights have been or may be violated. This can be done at any time by discussing such concerns
with members of the treatment team.
Health Information Rights
You may have many rights concerning the confidentiality of your health information. You have the right:
1. To request restrictions on the health information we may use and disclose for treatment, payment,
and health care operations. We are not required to agree to these requests.
2. To request restrictions; please send a written request to the address below.
3. To receive confidential communications of health information about you in a certain manner or at a
certain location. For instance, you may request that we only contact you at work or via mail.
4. To make such a request, you must write to us at the address below, and tell us how or where you
wish to be contacted.
5. To inspect or copy your health information: You must submit your request in writing to the address
below. If you request a copy of your health information we may charge you a fee for the cost of copying,
mailing, or other supplies. In certain circumstances, we may deny your request to inspect or copy your
health information. If you are denied access to your health information, you may request that the denial be
reviewed. Another licensed healthcare professional will then review your request and the denial. The
person conducting the review will not be the person who denied your request. We will comply with the
outcome of the review
6. To amend health information: If you feel that health information we have about you is incorrect or
incomplete, you may ask us to amend the information.
7. To request an amendment, you must write to us at the address above. You must also give us a reason
to support your request. We may deny your request to amend your health information if it is not in writing
or does not provide a reason to support your request. We may also deny your request if:
a. The information was not already created by us unless the person who created the information
is no longer available to make the amendment,
b. The information is not part of the health information kept by or for us,
c. The information is not part of the information you would be permitted to inspect or copy, or
d. The information is accurate and complete
To receive an accounting of disclosures of your health information: To receive an accounting of all
disclosures of your healthcare information:
1. You must submit your request in writing to your clinic. Not all health information is subject to this
request.
2. Your request must state a time period, no longer than 6 years and may not include dates before
April 14, 2003
3. Your request must state how you would like to receive the report (paper, electronically).
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The first accounting you request within a 12-month period is free.
For additional requests, we may charge you the cost of providing the accounting. We will notify you of this
cost and you may choose to withdraw or modify your request before charges are incurred.
To receive a paper copy of this Notice upon request, even if you have agreed to receive the Notice
electronically you must submit a request for a paper notice in writing to your assigned clinic.
All requests to restrict use of your health information for treatment, payment, and health care operations,
to inspect and copy health information, to amend your health information, or to receive an accounting of
disclosures of health information must be made in writing to the Medical Records Department.
PROHIBITIONS ON OTHER USES OR DISCLOSURES: We may not make any other use or disclosure
of your personal health information without your written authorization. Once given, you may revoke the
authorization by writing to the contact person listed below. Understandably, we are unable to take back
any disclosure we have already made with your permission.
C. PATIENT RESPONSIBILITIES
You will be expected within the limits of your abilities to assume a share of the responsibility for your
health care. Your responsibilities include being on time for scheduled events, or notify the appropriate
person if you will be late or need to cancel an appointment, participate in the formulation of your treatment
plan and be responsible for working on meeting your goals, treat members of your treatment team and
other clients with respect, and meet your financial and required documentation of records in a timely
manner.
All patients enrolled at the clinic are asked to be responsible for the following:
1. Be on time for scheduled appointments.
2. Notify the clinic 48 hours in advance if unable to keep a scheduled appointment.
3. Participate in the formulation of the treatment plan.
4. Treat the clinic staff, property, and other clients in the clinic with respect.
5. Make payment of the determined fee in a timely manner.
6. Submit the immunization record and physical exam that is no more than every 12 months.
7. Provide accurate and honest information to care providers and other staff.
D. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996
THIS NOTICE DESCRIBES HOW MEDICAL, DRUG AND ALCOHOL RELATED INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
General Information Information regarding your health care, including payment for health care, is
protected by two federal laws: the Health Insurance Portability and Accountability Acts of 1996 (HIPAA),
42 U.S.C 1320d et seq., 45 C.F.R Parts 160 & 164, and the Confidentiality Law, 42 U.S.C 290dd-2, 42
C.F.R Part 2. Under these laws, Community Behavioral Health may not say to a person outside
Community Behavioral Health that attend the program nor may Community Behavioral Health disclose
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any information identifying you as a mental health, alcohol or drug abuse client or disclose any other
protected information except as permitted by federal law.
Community Behavioral Health must obtain your written consent before it can disclose information about
you for payment purposes. For example, Community Behavioral Health must obtain your written consent
before it can disclose information to your health insurer in order to be paid for services. Generally, you
must also sign a written consent before Community Behavioral Health can share information for treatment
purposes or for health care operations. However, federal law enforcement permits Community Behavioral
Health to disclose with any qualified services organization/business associate pursuant to an agreement
with qualified services organization/business associates
1. For research audit or evaluations
2. To report a crime committed on Community Behavioral Health premises or against CBH personnel
3. To medical personnel in a medical emergency
4. To appropriate authorities to report suspected child abuse or neglect as allowed by a court order.
For example, Community Behavioral Health can disclose information without your consent to obtain legal
or financial services or to another medical facility to provide healthcare to you as long as there is a
qualified service organization/business associate agreement in place. Before Community Behavioral
Health can use or disclose any information about your health which is not described above, it must obtain
your specific written consent allowing them to make the disclosure. You may revoke any such written
consent in writing.
Your Rights: Under HIPAA you may have the right to request restrictions on certain uses and disclosures
of your health information. Community Behavioral Health is not required to agree to any restrictions you
request, but if it does agree, then it is bound by that agreement and may not use or disclose any
information which you have restricted except as necessary in a medical emergency.
E. COMMUNITY BEHAVIORAL HEALTH GRIEVANCE POLICY
Patients are encouraged to address complaints or concerns to his or her primary therapist or case
manager. If this staff person is unable to resolve the complaint, it is to be brought to the attention of the
following individuals depending upon the type of issue:
1. Clinical or Administrative Issue: Site Supervisor
2. Medical Issue: Medical Director
If a resolution is not reached, the patient will be provided with a Patient Grievance form to document the
complaint in writing. This form is forwarded to the Director who is responsible for investigating and making
recommendations for change or resolution of the grievance. The Patient Grievance form can be obtained
through request of receptionist or other staff person. The Patient Grievance form must be completed
before the grievance can be reviewed at the level of the Regional Director. Complaints will receive a
response concerning the incident verbally or in writing within seven (7) days.
If the grievance remains unresolved between the patient and the staff or the Director, the patient may
pursue the grievance with the local Core Services Agency. The following are contact numbers:
1. Wicomico County CSA: (410) 543-6981
2. Dorchester and Queen Anne's Counties CSA: (410)-770-4801
3. The Howard County Local Behavioral Health Authority 410-313-7316
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F. COMMUNITY BEHAVIORAL HEALTH DISCHARGE POLICY
Immediate agency discharge of the patient may occur upon the discretion of the management team for
any of the following behaviors which may compromise the outcome of mental health treatment and/or the
safety of staff or patients:
1. Tampering with prescriptions
2. Behaviors or information that suggest medication is being sought for the purpose of illegal use or
distribution instead of treatment use as directed or medication is being willfully misused for
another purpose
3. Threatening behaviors towards staff and other patients
4. Property destruction
5. Theft of property
6. Physically or verbally assaultive behaviors towards staff or other patients
7. Verbal threats to staff or other patients Chronic no shows (three consecutive no shows for any
agency program)
8. Failure to comply with individualized contract and treatment plan
9. Inappropriate sexualized behavior towards staff or other patients
10. Carrying a weapon or using any object as a weapon, or carrying drugs, or drug paraphernalia on
Community Behavioral Health property
11. Consecutive rescheduling or no shows to physician, therapist, and/or a combination of
appointments.
12. Other behaviors deemed grossly negligent, threatening, harmful or detrimental to staff or other
patients.
Upon immediate discharge, the patient will be provided a letter of discontinuation of services, effective
immediately. The patient may receive a 30 day prescription for prescribed medications and will not be
permitted readmission to any location of Community Behavioral Health.
G. NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
We understand that your health (including mental health) information is personal to you, and we are
committed to protecting the information about you. This Notice of Privacy Practice (or "Notice") describes
how we will use and disclose protected information and data that we receive or create related to your
health care. OUR DUTIES: We are required by law to maintain the privacy of your health information, and
to give you this Notice describing our legal duties and privacy practices. We are also required to follow the
terms of the Notice currently in effect.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: We will not use or disclose
your health information without your authorization, except in the following situations:
TREATMENT: We will use and disclose your health information while providing, coordinating or managing
your health care. For example, information obtained by a clinician, physician, or other member of your
treatment team will be recorded in your record and used to determine the course of treatment that should
work best for you. Your therapists and Psychiatrist will put in your record his or her expectations of the
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members of your treatment team. Members of your treatment team will then record the actions they took
and their observations. In that way, the therapist and Psychiatrist will know how you are responding to
treatment. We may also provide other healthcare providers with your information to assist him or her in
treating you. In order to ensure quality treatment the agency maintains various licensing and
accreditation. The licensing and accrediting agencies will have access to your information in the course of
monitoring agency performance and compliance to standards.
PAYMENT: We will use and disclose your medical information to obtain or provide compensation or
reimbursement for providing your health care. For example, we may send a bill to your or your health
plan. The information on or accompanying the bill may include information that identifies you, as well as
your diagnosis, procedures, and interventions used. As another example, we may disclose information
about you to your health plan so that the health plan may determine your eligibility for payment for certain
benefits.
HEALTH CARE OPERATIONS: We will use and disclose your health information to deal with certain
administrative aspects of you care, and to manage our business more efficiently. For example, members
of our staff may use information in your health record to assess the quality of care and outcomes in your
case and others like it. This information will then be used in an effort to improve the quality and
effectiveness of the care and services we provide.
BUSINESS ASSOCIATES: There are some services provided in our organization through contracts with
business associates. We may disclose your health information to our business associate so they can
perform the job we have asked them to do. However, we require the business associate to take
precautions to protect your health information.
NOTIFICATION OF FAMILY: We may use or disclose information to notify or assist in notifying a family
member, personal representative, or other person responsible for your care of your location and general
condition.
COMMUNICATION WITH FAMILY: We may disclose to a family member, close personal friend or any
other person you identify, health information relevant to that person's involvement in your care.
RESEARCH: consistent with applicable law we may disclose information to researchers when their
research has been approved by an institutional review board that has reviewed the research proposal and
established protocols to ensure the privacy of your health information.
PUBLIC HEALTH: As required by law, we may disclose your health information to public health or legal
authorities charged with preventing or controlling disease, injury, or disability, including child abuse and
neglect.
VICTIMS OF ABUSE, NEGLECT OR DOMESTIC VIOLENCE: We may disclose your health information
to appropriate governmental agencies, such as adult protective or social services agencies, if we
reasonably believe you are a victim of abuse, neglect, or domestic violence.
HEALTH OVERSIGHT: In order to oversee the health care system, government benefits programs,
entities subject to governmental regulation and civil rights laws for which health information is necessary
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to determine compliance, we may disclose your health information for oversight activities authorized by
law. Such as audits and civil, administrative, or criminal investigations.
COURT PROCEEDING: We may disclose your health information in response to requests made during
judicial and administrative proceedings, such as court orders or subpoenas.
LAW ENFORCEMENT: Under certain circumstances, we may disclose your health information to law
enforcement officials. These circumstances include reporting certain things required by certain laws (such
as reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited
information concerning identification and location at the request of a law enforcement official, reports
regarding suspecting suspected victims of crimes at the request of a law enforcement official, reporting
death, crimes on our premises, and crimes in emergencies.
INMATES: If you are an inmate of a correctional institution or under the custody of a law enforcement
official, we may release health information about you to the correctional institution or law enforcement
official. This release would be necessary (1) for the institution to provide you with health care; (2) to
protect your health and safety or the health and safety of others; or (3) for the safety and security of the
correctional institution.
THREATS TO PUBLIC HEALTH OR SAFETY: We may disclose or use health information when it’s our
good faith belief, consistent with ethical and legal standards, that it is necessary to prevent or lessen a
serious and imminent threat or is necessary to identify or apprehend an individual.
SPECIALIZED GOVERNMENT FUNCTIONS: Subject to certain requirements, we may disclose or use
health information for military personnel and veterans, for national security and intelligence activities, for
protective services for the President and others, for medical suitability determinations for the Department
of State, for correctional institutions and other law enforcement custodial situations, and for government
programs providing public benefit.
WORKERS COMPENSATION: We may disclose health information when authorized and necessary to
comply with laws relating to workers compensation or other similar programs.
OTHER USES: We may also use and disclose your personal health information for the following
purposes:
1. To contact you to remind you of an appointment or treatment;
2. To describe or recommend treatment alternatives to you;
3. To furnish information about health-related benefits and services that may be of interest to you.
H. COMMUNITY BEHAVIORAL HEALTH FINANCIAL POLICY GENERAL PAYMENT POLICIES
Patients are requested to present a current insurance card at every visit. It is the patient's responsibility to
update the office when their insurance information changes. Co-payments and account balances are due
at the time of service. Payment of your financial responsibility is due upon the receipt of our bill. We
accept cash, check, Visa, MasterCard, and Discover. Accounts become past due after thirty (30) days.
There will be a $25.00 fee assessed for all checks returned as Non-Sufficient Funds (NSF). In the event
that another party is the guarantor for our patient's insurance carrier, said guarantor is responsible for
payment. Insurance Billing Information If your insurance company has not paid your account in full within
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ninety (90) days, the balance may be automatically transferred to your responsibility for payment upon
receipt of statement. You will be responsible to pay any charges associated with care received that your
insurance determines is NOT a covered benefit. You must be aware of your own insurance benefits.
When in doubt contact your insurance company directly for clarification. Medicare As a Medicare patient
you are responsible for your deductible and for the difference between the approved charge and the
amount Medicare pays. If you have supplemental insurance we will bill it for you. Any remaining balance
will be billed to you. Non-Participating Insurance Plans or Out of Network As a service to our patients, we
will bill as a nonparticipating claim. All outstanding balances are the responsibility of the patient, to be
paid within the time-frame outlined in the policy above. My signature at the end of this consent form
indicates I have read the Financial Policies of Community Behavioral Health, and agree to comply with
them. In addition, Community Behavioral Health has my permission to communicate with my insurance
carrier in order to obtain reimbursement.
My signature at the end of this consent form indicates I authorize my insurance carrier to make payments
to Community Behavioral Health for services rendered to me or my dependent by Community Behavioral
Health. Should my insurance company deny Community Behavioral Health payment, I understand that I
am financially responsible for the charges.
I. MEDICARE PATIENTS ONLY: CHRONIC CARE MANAGEMENT (CCM) TREATMENT CONSENT
As a patient with two or more chronic conditions such as long term (chronic) heart, lung, kidney disease,
infectious disease, depression, psychosis, or anxiety, you may benefit from a new program that
Community Behavioral Health offers all Medicare patients. Our goal is to make sure you get the best care
possible from everyone that is involved with your care. We can help coordinate your visits with other
doctors, facilities, lab, radiology, or other testing; we can talk to you on the phone about your symptoms;
we can help you with the management of your medications; and we will provide you with a
comprehensive care plan. Medicare will allow us to bill for these services during any month that we have
provided at least 20 minutes of non-face-to-face care of you and your conditions. You must provide your
consent to participate once a year. The clinician in charge of your care is Virbala Patel, RPH.
Sometimes other staff from our practice will talk to you or handle issues related to your care, but please
know that your assigned clinician will supervise all care provided by our staff or clinicians who may be
involved in your care.
***You agree and consent to the following:
As needed, we will share your health information electronically with others involved in your care. Please
rest assured that we continue to comply with all laws related to the privacy and security of your health
information.
We will bill Medicare for this chronic care management for you once a month. Although you may or may
not come into the office every month, your account will reflect this charge and you will be responsible for
payment.
Our office will have a record of our time spent managing your care if you ever have a question about what
we did each month.
Only one physician can bill for this service for you. Therefore, if another one of your physicians has
offered to provide you with this service, you will have to choose which physician is best able to treat you
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and all of your conditions. Please let your physician or our staff know if you have entered into a similar
agreement with another physician/practice.
You have a right to:
1. A Comprehensive Care Plan from our practice to help you understand how to care for your
conditions so that you can be as healthy as possible.
2. Discontinue this service at any time for any reason.
Because your signature is required to end your chronic care management services, please ask any of our
staff members for the CCM termination form.
We believe that to achieve this goal there must be a partnership between the patient and their medical
provider. By remaining involved in the decisions regarding your health, health care and lifestyle, we can
develop a stronger relationship with you.
BEFORE YOUR CCM PHARMACIST ASSESSMENT CALL PLEASE USE THIS HANDY CHECKLIST
1. Make a list of any questions you have about your health including questions about dietary
recommendations and lifestyle.
2. Inform the CCM pharmacist of any other health care providers that you have visited in the last
month and the reason why you visited them.This includes urgent care or the ER.
3. Have a list of all of your prescribed medications ready, over-the counter, herbal and dietary
supplements.
4. Inform the CCM nurse of any refills that you require.
5. Inform the CCM nurse of any new problems that may have developed in the last month.
6. Confirm the date of your next CCM nurse assessment call as well as the date of your next office
visit with us. As a reminder, please use the dedicated phone number that was provided to you
during your first CCM nurse assessment call so you can call us after hours if necessary, this
provides you 24/7 access to your physician or to the covering physician partner.
7. Register for our patient portal. This is a good way to communicate with your doctor and CCM
nurse as well as to view your care plan. If you want to designate a caregiver to have access to
your record, please ask our office for the forms to sign. With continued partnership in the CCM
program, we hope to optimize your health, increase your quality of life and prevent
hospitalization.
Our goal is to provide you with the best care possible, to keep you out of the hospital, and to minimize
costs and inconvenience to you due to unnecessary visits to doctors, emergency rooms, labs, or
hospitals. We know your time and your health is valuable and we hope that you will consider participation
in the program with our practice.
J. TELEMEDICINE AND TELE-BEHAVIORAL SERVICES
INTRODUCTION
Telemedicine involves the use of electronic communications to enable health care providers at different
locations to share individual patient medical information for the purpose of improving patient care.
Providers may include primary care practitioners, specialists, and/or sub-specialists. The information may
be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: Patient
medical records Medical images Live two-way audio and video Output data from medical devices and
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sound and video files electronic systems used will incorporate network and software security protocols to
protect the confidentiality of patient identification and imaging data and will include measures to safeguard
the data and to ensure its integrity against intentional or unintentional corruption.
EXPECTED BENEFITS
Improved access to medical care by enabling a patient to remain in his/her psychiatric clinic (or at a
remote site) while the physician obtains test results and consults from healthcare practitioners at
distant/other sites.
More efficient medical evaluation and management.
Obtaining expertise of a distant specialist.
POSSIBLE RISKS
As with any medical procedure, there are potential risks associated with the use of telemedicine. These
risks include, but may not be limited to: In rare cases, information transmitted may not be sufficient (e.g.
poor resolution of images) to allow for appropriate medical decision making by the physician and
consultant(s) Delays in medical evaluation and treatment could occur due to deficiencies or failures of the
equipment In very rare instances, security protocols could fail, causing a breach of privacy of personal
medical information In rare cases, a lack of access to complete medical records may result in adverse
drug interactions or allergic reactions or other judgment errors
All patients participating in our telehealth services expected to abide by the following rules, regulations,
and policies:
1. Patients must have at least one in-person appointment per year for vital signs. If requested to
come in physically more often than once per year, you must be able to do so in order to receive
continued care.
2. Patients must come for in-person urine drug screen at any time upon provider request. If you do
not come in within 2 weeks of the request, your continued care with the agency will be reviewed
and you may be sent to a higher level of care.
3. Patients must complete requested lab work or other types of testing on-site. If you do not
complete your lab work in a timely manner, results may not be sent to us to make further clinical
determination. In such an event, the physician is not liable for any health complications, risks, or
damages.
4. Patients shall not be scheduled for virtual visits if a therapist, PRP worker, or psychiatrist
determines the patient needs in-person visits. In such an event, you must be available in your
home or in the clinic on time for your appointment.
5. Patients should be in their home or in a private location for a telehealth appointment. This leads
to a lesser likelihood of the leak of any confidential information. If you are not at your home
address, you must immediately inform the provider of your current location.
6. Patients who end an appointment abruptly or who answer provider phone calls in a manner by
which the provider believes there could be an emergency or crisis situation may result in the
13
provider contacting an emergency contact and sending emergency services to the patient's
address on file.
7. Patients who struggle with the use of telehealth technology for more than 3 appointments will be
asked to come in person for their appointments.
By initialing signing the consent below, I understand and agree to the following:
I understand that the laws that protect privacy and the confidentiality of medical information also apply to
telemedicine, and that no information obtained in the use of telemedicine which identifies me will be
disclosed to researchers or other entities without my consent.
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the
course of my care at any time, without affecting my right to future care or treatment.
I understand that I have the right to inspect all information obtained and recorded in the course of a
telemedicine interaction, and may receive copies of this information for a reasonable fee.
I understand that a variety of alternative methods of medical care may be available to me, and that I may
choose one or more of these at any time.
I understand that telemedicine may involve electronic communication of my personal medical information
to other medical practitioners who may be located in other areas, including out of state.
I understand that it is my duty to inform my psychiatrist of electronic interactions regarding my care that I
may have with other healthcare providers.
I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that
no results can be guaranteed or assured.
If any questions concerning my medication arise, I understand that Community Behavioral Health will
contact my telepsychiatrist or other telepractitioner, who will handle any questions I may have.
Since my participation is voluntary, I may request a transfer to another telebehavioral health clinician, if
available within the agency, provided I have addressed any complaints directly with the telebehavioral
health clinician treating me (or my child) and provided I have followed the necessary Grievance Policy
procedures (see Section E).
I understand that Community Behavioral Health may provide a staff member for all my sessions, and that
my insurance, if I have insurance, will be billed for the clinical time. I understand that my privacy and
confidentiality will be protected by the same HIPAA standards as apply for all other services rendered by
Community Behavioral Health, Any records concerning my treatment are the property of Community
Behavioral Health.
As part of the telepsychiatry service, I may be asked to take part in a brief satisfaction survey. If provided
with a survey, I understand its importance in improving service and accessing continued funding. I have
14
read this document and I hereby consent to participate in receiving behavioral health services via
TeleBehavioral Health video and/or audio-conferencing. I also understand that my confidentiality will be
protected in all cases when a survey is completed.
If I have questions, I know I can contact any member of my treatment team.
I understand I must adhere to the telehealth policies and procedures and my use of telehealth can be
revoked at any time by the treatment team if they determine I am unable to meaningfully engage in care
or there are safety concerns requiring my presence in person.
I have read and understand the information provided above regarding telemedicine, have discussed it
with my physician or such assistants as may be designated, and all of my questions have been answered
to my satisfaction. I hereby give my informed consent (or consent for my child) for the voluntary use of
telemedicine in my medical care. By signing at the bottom of the document, I hereby authorize
Community Behavioral Health to use telemedicine in the course of my diagnosis and treatment. I further
understand that all of my telebehavioral health/psychiatric services will be performed using video and/or
audio-conferencing equipment.
K. CRISP PARTICIPATION
Notice of Privacy Practices for CRISP Participation: We have chosen to participate in the Chesapeake
Regional Information Systems for our Patients, Inc. (CRISP), a regional health information exchange. As
permitted by law, your health information will be shared with this exchange in order to provide faster
access, better coordination of care and assist providers and public health officials in making more
informed decisions. You may opt-out and disable all access to your health information available through
CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or
through their website at www.crisphealth.org By signing the bottom of the document, I acknowledge that I
have received and agree to the aforementioned information.
L. ADVANCE DIRECTIVE FOR MENTAL HEALTH CARE
Maryland law gives the right to anyone 16 years of age and over to be involved in decisions about their
mental health treatment. The law states individuals have the right to make decisions in advance, including
mental health treatment decisions, through a process called advanced directive. The advanced directive
is designed to assist with pre-planning should an individual become unable to make informed decisions.
Advance Directive information was offered to the mentioned patient or Parent/Legal Guardian, as
requested, and this is indicated by the signature at the bottom of the document. Disclaimer: Advance
Directives are important legal documents. Individuals are advised to seek legal advice should clarification
of laws be needed. Community Behavioral Health can provide you with an information based packet but
we cannot provide you with legal advice.
M. INFECTION PREVENTION AND CONTROL
Community Behavioral Health has an infection prevent and control plan to reduce risk and spread of
infection Community Behavioral Health Leaders are to report infection surveillance, prevention, and
control information to organization staff consistent with their responsibilities for infection prevention and
control activities. Reporting of this information about the occurrence of infections to local, state, and
federal public health authorities is to be done in accordance with law and regulation. When patients or
15
staff have or are suspected of having an infectious disease that puts others at risk, leaders of Community
Behavioral Health reserve the right to refer the suspected individuals for assessment and potential
testing, prophylaxis/treatment, or counseling prior to their return to clinic.
My signature at the bottom of this document indicates that I am aware that if I, or any individual usually
brought to Community Behavioral Health, suspect/s or confirm/s I/they have a contact communicable,
airborne communicable, or liquid communicable condition (for example: head lice or bed bugs), I will
notify the relevant staff of the reason for not attending Clinic, and I will not come to, or bring them to
Community Behavioral Health.
N. COMMUNITY BEHAVIORAL HEALTH CONSENT ACKNOWLEDGEMENT AND SIGNATURES
Patient Name:_____________________________________________
Date of Birth:___________________
I have received a copy of the following policies which are also displayed in the lobby:
A. GENERAL CONSENT FOR TREATMENT
B. PATIENT BILL OF RIGHTS
C. PATIENT RESPONSIBILITIES
D. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996
E. COMMUNITY BEHAVIORAL HEALTH GRIEVANCE POLICY
F. COMMUNITY BEHAVIORAL HEALTH DISCHARGE POLICY
G. NOTICE OF PRIVACY PRACTICES
H. COMMUNITY BEHAVIORAL HEALTH FINANCIAL POLICY
I. MEDICARE PATIENTS ONLY: CHRONIC CARE MANAGEMENT TREATMENT CONSENT
Check and Initial the section that applies:
[ ], Patient/Parent/Guardian, AGREE to participate in the Chronic Care Management program.
INITIALS:_________
[ ], Patient/Parent/Guardian do not agree to participate in the Chronic Care Management program.
INITIALS:_________
J. TELEMEDICINE AND TELEBEHAVIORAL SERVICES
K. CRISP PARTICIPATION
L. ADVANCE DIRECTIVE FOR MENTAL HEALTH CARE
Check and Initial the section that applies:
[ ] * My date of birth is___________, and I have an Advance Directive. (Please send a copy of your
Advance Directive to CBH).
INITIALS:_________
[ ] * I do not have an Advance Directive, and I would like to receive an information packet regarding
Advance Directives.
INITIALS:_________
[ ] * I do not have an Advance Directive, and I would NOT like to receive an information packet
regarding Advance Directives.
INITIALS:_________
M. INFECTION PREVENTION AND CONTROL
16
SIGNATURES FOR ENTIRE CONSENT FOR TREATMENT DOCUMENT:
My signature below shows that I have read, understood, and accept all of the above terms of consent for
treatment. I understand this consent is valid for one year and I have the right to withdraw consent at any
time and for any reason.
I further understand I will be asked for consent and re-signature annually.
Signature of Patient or Patient Guardian:_______________________________________
Date:____________________________
COMMUNITY BEHAVIORAL HEALTH
426 Dorchester Avenue, Cambridge, MD 21613
202 Coursevall Drive Unit 107, Centreville, MD 21617
300 Scheeler Road, Chestertown, MD 21620
10774 Hickory Ridge Road, Columbia, MD 21044
8614 Ocean Gateway, Easton, MD 21601
30519 Prince William Street, Princess Anne, MD 21853
17
809 + 821 Eastern Shore Drive, Salisbury, MD 21804
107 East Market Street, Snow Hill, MD 21863
www. communitybehavioralhealth.net
Phone: (844) 224-5264 Fax: (888) 509-0010
CONSENT TO RECEIVE/RELEASE
INFORMATION
Patient Name:__________________________________________
Date of Birth:___________________________________________
Date:_________________________________________________
By my signature below, I, ____________________ (Patient Name) or the parent/guardian authorize
Community Behavioral Health (CBH) to RECEIVE and/or PROVIDE information regarding my
records and treatment information from and/or to the physician, other types of healthcare providers,
therapist, school, social security administration, the insurance company, or another type of facility or
professional listed above my signature at the bottom.
The information exchanged is for the following purposes (any other use is prohibited):
X Coordination of care
X Other:_________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Information to be Exchanged (if available or applicable):
●
●
●
●
●
Most recent medical information including current medications, diagnoses, lab results and
imaging (ECG results, brain imaging reports if available).
Verbal and written exchange between providers, teachers, or relatives.
Vaccination record
School records
Individualized Education Plans
18
●
Other if not listed here: {TextInput}
I understand that I may withdraw this consent at any time, either verbally or in writing except to the
extent that action has been taken on reliance on it. This consent will last while I am being treated by
Community Behavioral Health unless I withdraw my consent during treatment. This consent will
expire 365 days after I complete my treatment unless Community Behavioral Health is otherwise
notified by me. I understand that the records to be released may contain information pertaining to
psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may also
contain confidential information about communicable diseases including HIV (AIDS) or related
illness. I understand that these records are protected by the Code of Federal Regulations Title 42
Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further
disclosures to third parties without the express written consent of the patient. I acknowledge that I
have been notified of my rights pertaining to the confidentiality of my treatment information/records
under 42 CFR Part 2, and I further acknowledge that I understand those rights.
Enter Primary Care Provider and/or Practice Name here:________________________________
Address:_________________________________________________________________________
Phone number:___________________________________________________________________
Fax number (if known):_____________________________________________________________
Enter School Name here:__________________________________________________________
Address:_________________________________________________________________________
Phone number:___________________________________________________________________
Fax number (if known):_____________________________________________________________
Enter Relative Name(s) here:_______________________________________________________
Address:_________________________________________________________________________
Phone number:___________________________________________________________________
Fax number (if known):_____________________________________________________________
Enter Other Provider or Facility Name(s) here:________________________________________
Address:_________________________________________________________________________
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Phone number:___________________________________________________________________
Fax number (if known):_____________________________________________________________
Signature of Patient or Parent/Guardian of Patient:_____________________________________
Date:___________________________________________________________________________
20
COMMUNITY BEHAVIORAL HEALTH
426 Dorchester Avenue, Cambridge, MD 21613
202 Coursevall Drive Unit 107, Centreville, MD 21617
300 Scheeler Road, Chestertown, MD 21620
10774 Hickory Ridge Road, Columbia, MD 21044
8614 Ocean Gateway, Easton, MD 21601
30519 Prince William Street, Princess Anne, MD 21853
809 + 821 Eastern Shore Drive, Salisbury, MD 21804
107 East Market Street, Snow Hill, MD 21863
www. communitybehavioralhealth.net
Phone: (844) 224-5264 Fax: (888) 509-0010
NEW PATIENT QUESTIONNAIRE
Thank you for contacting Community Behavioral Health for your behavioral healthcare needs. Our
Community Mental Health Clinic has met the high standards required, earning accreditation by JCAHO,
The Joint Commission on Accreditation of Healthcare Organizations. We provide mental health and
substance use treatment in 8 Maryland counties, including the Eastern Shore.
Our services include:
●
●
●
●
●
●
●
●
●
●
Targeted psychotherapies for specific conditions provided in individual, family, couples, and group
format
Intensive Outpatient Program treatment
Comprehensive comorbid Substance Use and Mental Health (SAMH) treatment, including MAT
(Medically Assisted Treatment), which is the gold standard for treatment of substance use
disorders because of the superior response rates
Computerized assessment technology for diagnosing Attention Deficit (ADHD) Disorders
TMS (Transcranial Magnetic Stimulation) for neurological and psychiatric disorders
Spravato (esketamine) nasal spray for severe treatment resistant depression
Long acting injectable forms of medication
Psychiatric Rehabilitation Program services (PRP)
Respite care
School based mental health treatment
This is a lengthy questionnaire, but our purpose is to save you time once you start treatment, and to help
us recognize which of our many options will best serve you. Our goal is to provide you with all you need to
recover and thrive. Please answer as many as you can and skip questions which do not apply to
you. The more complete your questionnaire, the more likely we can give you appropriate
treatment.
21
A. PATIENT INFORMATION
Full Name (include preferred or nicknames):
Date of Birth (MM/DD/YYYY):
Home Address (Including City, State, and Zip Code):
Best Phone Number:
Best Email Address:
Social Security Number:
Race:
❏
❏
❏
❏
❏
❏
❏
African American/Black
Asian/Pacific Islander
Caucasian/White
First/Native American
Latinx
Two or More Races
Other
Gender:
❏
❏
❏
❏
❏
❏
Female
Male
Transgender Female
Transgender Male
Other:
Prefer Not to Say
Guardian Information (If Not Applicable, Go to Section B)
Name of Legal Guardian(s):
Relationship to Patient:
Best Phone Number:
Best Email Address:
Guardian's Home Address (Including City, State, and Zip Code):
Amount of times custody has changed in the last 3 years:
If the patient has multiple custodians, please be sure to bring paperwork identifying the guardian
responsible for medical decision-making.
22
B. EMERGENCY CONTACT INFORMATION
By law, we are required to request two (2) emergency contacts.
EMERGENCY CONTACT 1
Name:
Relationship to Patient:
Best Phone Number:
Best Email Address:
Home Address (Including City, State, and Zip Code):
EMERGENCY CONTACT 2
Name:
Relationship to Patient:
Best Phone Number:
Best Email Address:
Home Address (Including City, State, and Zip Code):
C. INSURANCE INFORMATION
Please ensure this section is complete and matches your insurance card. There may be delays in booking
your appointment if your insurance cannot authorize treatment.
INSURANCE CARRIER NAME:
INSURANCE CARRIER PLAN:
INSURANCE MEMBER ID NUMBER:
GROUP NUMBER:
CLAIMS PHONE NUMBER:
CLAIMS ADDRESS (INCLUDING CITY, STATE, AND ZIP):
POLICY HOLDER NAME:
POLICY HOLDER DATE OF BIRTH:
POLICY HOLDER SOCIAL SECURITY NUMBER:
SECONDARY INSURANCE CARRIER NAME:
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SECONDARY INSURANCE CARRIER PLAN:
SECONDARY INSURANCE MEMBER ID NUMBER:
SECONDARY GROUP NUMBER:
SECONDARY CLAIMS PHONE NUMBER:
SECONDARY CLAIMS ADDRESS (INCLUDING CITY, STATE, AND ZIP):
Will you require a sliding scale payment option?
❏ Yes
❏ No
D. REASON FOR SEEKING CARE
Preferred treatment locations (check whichever locations are convenient for you):
❏ Dorchester County
426 Dorchester Avenue
Cambridge, MD
❏ Howard County
10774 Hickory Ridge Road
Columbia, MD
❏ Kent County
300 Scheeler Road
Chestertown, MD
(School based, Substance Use & Co-occurring treatment programs only)
❏ Queen Anne’s County 142 Coursevall Drive
Centreville, MD
❏ Somerset County
30519 Prince William Street
Princess Anne, MD
(Substance Use & Co-occurring treatment programs only)
❏ Talbot County
8614 Ocean Gateway
Easton, MD
❏ Wicomico County
809 Eastern Shore Drive
Salisbury, MD
❏ Worcester County
107 E Market Street
Snow Hill, MD
(Also choose another location to use until this one opens)
Were you looking for any of the following specific services?
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
Bariatric surgery clearance
Other surgical clearance
Gender affirmation evaluation
Couples therapy
Family therapy
Group therapy
IOP (Intensive Outpatient Program)
Social skills building
Substance Abuse Treatment
Medication Assisted Substance Abuse Treatment (including sublicade, suboxone, or subutex)
Psychiatric Rehabilitation Program (PRP) services
Respite
Spravato (esketamine) nasal spray
TMS (Transcranial Magnetic Stimulation)
Please explain your reason for seeking care at Community Behavioral Health now. What is the
main reason you are coming to treatment now? When did your symptoms begin, how have they
progressed, and how are they impacting your life now?
24
E. CARE COORDINATION INFORMATION
(enter NONE if appropriate)
1. Primary Care Provider (PCP) Name, Number, Address, & Month/Year of Last Physical Exam:
2. Preferred Pharmacy Name, Number, & Location:
3. Dentist Name, Number, & Month/Year of Last Visit:
4. Optometrist (O.D.) or Ophthalmologist (M.D./D.O.) Name, Number, & Month/Year of Last Visit:
5. Please list the names, specialties, locations, and numbers of any of your other healthcare
providers:
Please ask each healthcare provider to fax your records, labs, ECG, and immunization records to
COMMUNITY BEHAVIORAL HEALTH’S FAX at 888-509-0010.
F. MEDICAL HISTORY
(enter NONE if appropriate)
1. MEDICAL CONDITIONS: Please write out past, resolved, and current medical problems (e.g.
high blood pressure, seizures, head injuries, loss of consciousness, brain hemorrhages, COPD,
heart disease, gout, diabetes, thyroid problems, etc.).
2. SURGERY: List all surgeries with the approximate date or your age for each one (e.g. appendix,
C-section, bypass, pacemaker, etc.).
3. OTHER MEDICAL TREATMENT and HOSPITALIZATIONS: List the reasons, dates, and
outcomes of any hospitalizations you've had for serious medical problems.
4. CURRENT NON-PSYCHIATRIC MEDICATIONS: List all of your current non-psychiatric
medications, vitamins, minerals, herbs, or supplements you are taking. Include name, dose,
number you usually take per day, who prescribes it, and what each is for.
25
5. CURRENT PSYCHIATRIC MEDICATIONS: List all current medications or supplements you take
for mental health reasons or addictions. Include the name, dose, number you take each day, what
they are for, and how long you have been on each. Please indicate if you are taking your
medication regularly or if you forget to take your medicine often.
6. PREVIOUS PSYCHIATRIC MEDICATIONS: List all PREVIOUS medications or supplements you
take for mental health reasons or addictions. Include the name, dose, number you took each day,
what they were for, how long you were taking each, and why you stopped them. It is a
requirement to provide all requested information in order to proceed with TMS or Spravato
treatment.
7. SIDE EFFECTS - What side effects (like dry mouth) do you have, and from which of your
medications? Write NONE if appropriate.
8. MEDICATION ALLERGIES: What medications have you had an allergic reaction to, what
reactions did you have and where (e.g. itchy bumps on the lower back) and what was the severity
of the allergic reactions? Write NO MED ALLERGIES if appropriate.
9. MEDICAL MARIJUANA: Do you have a medical marijuana card? Mark an X next to the statement
that applies.
❏ Yes. Please write the name of the individual who has given you the medical marijuana card:
❏ No
10. MENTAL HEALTH TREATMENT HISTORY: Please skip questions that do not apply to you.
Please provide the names, locations, dates of treatment, reason for receiving care, and
reason for stopping care in each section. It is a requirement to provide all requested
information in order to proceed with TMS or Spravato treatment.
OUTPATIENT (CLINIC OR OFFICE) INDIVIDUAL, FAMILY, GROUP, OR COUPLES THERAPY
TREATMENT HISTORY:
OUTPATIENT (CLINIC OR OFFICE) MEDICATION TREATMENT HISTORY: Please indicate if
you received medication from your primary care provider, a psychiatrist, a physician assistant, a
nurse practitioner, or another type of provider.
INTENSIVE OUTPATIENT OR PARTIAL HOSPITAL TREATMENT HISTORY:
26
INPATIENT (PSYCHIATRIC HOSPITAL) TREATMENT HISTORY:
RESIDENTIAL PSYCHIATRIC TREATMENT HISTORY:
SUBSTANCE USE TREATMENT HISTORY: Please indicate if you went to education classes,
had court ordered treatment, groups such as AA/NA, if you have a sponsor, if you attended
rehabilitation, detoxification units or programs, received Medication Assisted Treatment (MAT), or
went to any other substance use specific treatment.
ANY OTHER PSYCHIATRIC TREATMENT HISTORY: Please indicate any spiritual, alternative,
or complementary treatments you may have received.
Do you have a history of suicide attempts, intentional overdoses, cutting, or other forms of self
injury? Mark an X next to the statement that applies.
❏ Yes. Please give details:
❏ No
Do you have a history of assaults, aggression, or property destruction? Mark an X next to the
statement that applies.
❏ Yes. Please give details:
❏ No
G. LIFESTYLE
1. EXERCISE: Mark an X by your current level of physical activity.
❏ Sedentary (no exercising)
❏ Light (e.g. doing housework)
❏ Moderate (e.g. walking)
❏ Vigorous (e.g. gym workout)
2. SEATBELTS:How often do you wear your seatbelt? Mark an X next to the circumstance that
applies to you.
❏ Never
❏ Sometimes
❏ Most of the time
❏ Always
3. FIREARMS: Do you have access to any guns? Mark an X next to the statement that applies.
❏ Yes. Please indicate what types, how many, and how they are stored:
❏ No
4. IF APPLICABLE - SEXUAL HEALTH: Please skip if this section does not apply to you.
a. If sexually active, what do you use to prevent pregnancy or sexually transmitted
infections or diseases (STIs/STDs)?
27
b. Have you ever had any STIs/STDs? (e.g. chlamydia, crabs/pubic lice, genital warts,
gonorrhea, hepatitis, HPV, mycoplasma genitalium, syphilis, trichomoniasis?) Write
NONE if appropriate.
5. IF APPLICABLE - PREGNANCY: Please skip if this section does not apply to you.
a. Are you trying to become pregnant?
b. How many times have you been pregnant?
c.
Have you had complications during any of your pregnancies?
d. How many children have you had?
e. Is there any possibility that you could be pregnant now?
6. NUTRITION
a. Do you regularly skip meals on purpose?
❏ Yes
❏ No
If yes, explain:
b.
Do you binge or eat to the point of feeling uncomfortable?
❏ Yes
❏ No
If yes, explain how much you are eating, how often, and if you induce vomiting after:
c.
Have you ever been diagnosed with an eating disorder?
❏ Yes
❏ No
If yes, explain which one, the diagnosis, and the treatment you received:
d. Have you had unintentional weight loss or gain of at least 10 pounds within the last 3
months?
❏ Yes
❏ No
If yes, explain whether it was a gain or a loss and how much:
e. Have you had a decrease/reduction or increase in your food intake?
❏ Yes
❏ No
If yes, explain:
f.
Do you have any food allergies or a dietary intolerance/special diet?
❏ Yes
❏ No
28
If yes, explain:
g. Do you have dental problems or issues with chewing, swallowing, constipation, nausea,
or vomiting during or after meals?
❏ Yes
❏ No
If yes, explain:
H. SUBSTANCE USE AND SUBSTANCE USE TREATMENT HISTORY
For each substance, we will ask you about your current and past use. Your honest information will help us
give you what you need to reach your goals and avoid medication or other treatment interactions that
could be harmful. It is a requirement to provide all requested information in order to proceed with
TMS or Spravato treatment.
Mark an X in the box that applies to you and fill in the follow up question boxes with explanations.
❏ Mark an X in this box if you have never drunk, eaten, smoked, inhaled, injected, vaped or
used any topical substance ever and skip this section.
1. ALCOHOL
❏ I have never tried any form of alcohol
❏ I drink or have drank alcohol. If you selected this option, please answer the questions
below.
● How old were you when you first drank?
●
Have you ever had a blackout?
●
Have you ever had a DUI/DWI charge?
●
How much alcohol do you drink in a single sitting or did you drink in a sitting (if
you have stopped)?
●
How often have you been drinking over the past 30 days?
●
When did you last drink any alcohol (e.g. beer, wine, or liquor)?
●
What is the longest time you have gone without drinking and when was that?
●
Explain when you have stopped drinking, if you ever had tremors, felt very
agitated, or had seizures requiring tapering or hospitalization.
2. TOBACCO
❏ I have never tried any form of tobacco (including dip, vaping, cigars, or other nicotine
products)
❏ I do use tobacco (including dip, vaping, cigars, or other nicotine products). If you selected
this option, please answer the questions below.
● How old were you when you first tried any form of tobacco and what was it?
●
What types, how much and how often do you use tobacco now?
●
What is the longest you've gone without using tobacco and when?
29
●
How have you quit tobacco in the past?
●
When did you last use tobacco?
3. MARIJUANA/THC
❏ I have never tried any form of marijuana, THC, cannabinoid, CBD, or a similar substance
ever.
❏ I have used/do use marijuana, THC, cannabinoid, CBD, or a similar substance. If you
selected this option, please answer the questions below.
● How old were you when you first tried any form of marijuana and what was it?
●
What types, how much and how often do you use any form of marijuana now?
●
●
What is the longest you've gone without using any form of marijuana and when?
How have you quit any form of marijuana in the past?
●
When did you last use any form of marijuana?
4. COCAINE
❏ I have never tried any form of cocaine (including crack cocaine).
❏ I have used/do use cocaine (including crack cocaine). If you selected this option, please
answer the questions below.
● How old were you when you first tried any form of cocaine and what was it?
●
What types, how much and how often do you use any form of cocaine now?
●
What is the longest you've gone without using any form of cocaine and when?
●
How have you quit any form of cocaine in the past?
●
When did you last use any form of cocaine?
●
What medical, legal, or financial problems has your cocaine use caused?
30
5.
OPIOIDS
❏ I have never tried any form of opioids (heroin, pain meds, opium etc)
❏ I have used/do use opioids (heroin, pain meds, opium etc). If you selected this option,
please answer the questions below.
● How old were you when you first tried any form of opioids and which were they?
●
What types, how much and how often do you use any form of opioids now?
●
What is the longest you've gone without using any form of opioids and when?
●
How have you quit any form of opioids in the past?
●
When did you last use any form of opioids?
●
What medical, legal, or financial problems has your opioid use caused (e.g.
overdose)?
6. OTHER SUBSTANCES: If you have used any other substances (e.g. crystal meth, inhalants,
LSD, mushrooms, recreational use of prescribed medications, or any other depressants,
stimulants, or hallucinogens), please give details including the name, the way you take them
(inhaled, swallowed, smoked, injected, or other), how often you take them, when you last took
them, your longest period of sobriety, and which are the hardest to stop, or any medical (e.g.
overdose or other health problems), legal, or financial problems they have caused.
7. DRUGS & ALCOHOL USE SCREENING QUESTIONS
CAGE SCREENING for ages 18 and Over (answer with YES or NO)
C: Have you ever felt you needed to CUT down on your drinking or drug use?
❏ Yes
❏ No
A: Have people ANNOYED you by their criticism of your drinking or drug use?
❏ Yes
❏ No
G: Have you ever felt GUILTY about your drinking or drug use?
❏ Yes
❏ No
E: Have you ever needed drugs or alcohol as an EYE-Opener to feel functional?
❏ Yes
❏ No
CRAFFT for ages 14 to 21 (answer with YES or NO)
C: Have you ever ridden in a CAR driven by someone (including yourself) who was "high," or had been
using alcohol or drugs?
❏ Yes
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❏ No
R: Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
❏ Yes
❏ No
A: Do you ever use alcohol or drugs while you are by yourself, or ALONE?
❏ Yes
❏ No
F: Do you ever FORGET things you did while using alcohol or drugs?
❏ Yes
❏ No
F. Do your FAMILY or FRIENDS ever say that you should cut down on your drinking or drug use?
❏ Yes
❏ No
T: Have you ever gotten into TROUBLE while you were using alcohol or drugs?
❏ Yes
❏ No
I. SOCIAL AND RELATIONAL CIRCUMSTANCES
1. UPBRINGING: Who did you grow up with? Please include grandparents, uncles, aunts, siblings,
friends, adopted parents, foster families, pets, or anyone else in your home until you began living
independently.
2. SIBLINGS: If applicable, please list any of your siblings, their ages, if they have different mothers
and/or fathers to you, if they live with you, live near you, are far away, estranged, or if they have
passed away.
3. CHILDREN: If applicable, please list all your children, the year each was born, and where each
lives.
4. CURRENT LIVING: What kind of home do you live in and do you live with anyone? Please
include any children, pets, renters, or other individuals in your current household.
5. CURRENT HOUSING: Do you or a person you live with rent or own your current living space?
Please indicate if you are homeless, in a group home, or transitioning between homes.
6. CUSTODY: Does anyone have primary custody, joint custody, or power of attorney over you?
Please explain
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7. SUPPORTS: What social contacts do you have (important relationships, activities, church, social
groups)?
8. SPIRITUALITY: What gives your life meaning (e.g. faith, place of worship, belief system) and how
does it help you? Do you identify with a religion or other belief system?
9. ABUSE/EXPLOITATION
Has anyone ever behaved in a way that was emotionally, verbally demeaning or abusive to you?
❏ Yes - How old were you during that first experience?
❏ No - Is anyone behaving that way with you now?
❏ Yes
❏ No
Has anyone ever behaved in a way that was physically abusive or aggressive with you?
❏ Yes - How old were you during that first experience?
❏ No - Is anyone behaving that way with you now?
❏ Yes
❏ No
Has anyone ever been sexual with you in a way you did not want, or felt you couldn't say no?
❏ Yes - How old were you during that first experience?
❏ No - Is anyone behaving that way with you now?
❏ Yes
❏ No
Have you ever witnessed another person being abused?
❏ Yes - How old were you during that experience and are you still witnessing abuse?
❏ No
Please add anything else that may be helpful for your therapist and psychiatrist to know:
10. TRANSPORTATION: What is your primary mode of transportation? Mark an X next to all that
apply
❏ Your car or truck
❏ Medical transportation
❏ A borrowed vehicle
❏ Friend or relative
❏ Public transportation
❏ No transportation
❏ Taxi
❏ Other, explain:
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11. FINANCES AND OCCUPATION
a. What were your childhood career goals?
b. What are your current career goals?
c.
What are the longest jobs you've had and for how long each?
d. What is your current or most recent job and when did it start?
e. If you're not working, when and why did you stop and what gets in the way of working
now?
f.
Do you have difficulty figuring or managing money?.
g. Which bills are you behind in paying?
h. How do you survive financially (e.g. child support, disability, food stamps, inheritance, job,
partner works, retirement income, savings, TCA)?
i.
If you've filed for bankruptcy, what were the circumstances?
j.
Have you ever stopped meds for lack of insurance, money or copays, and what were the
circumstances?
12. MILITARY: Have you ever been in the military? If so, what was your branch, highest rank, and
type of discharge?
13. NATURAL DISASTER: Have you ever been in a natural disaster (e.g. hurricane, earthquake,
etc.)?
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14. LEGAL: Mark an X next to the box if applicable to you and enter details in the following box next
to the statement that applies to you.
❏ I have no current or past legal circumstances (including custody issues, pending court dates,
peace orders, arraignments, probation, or parole). If you have selected this box, please skip this
section.
❏ I am involved in a custody battle. Please explain:
❏ I have had charges filed against me (e.g. DUI, CDS, theft, assault, peace order). Please explain:
❏ I have filed a peace order against someone. Please explain:
❏ I have been incarcerated in jail or prison. Please explain where, what for, and how long:
❏ I am on probation or parole. Please explain what for and how long:
❏ I have DSS involvement. Please explain:
❏ I have DJS involvement. Please explain:
J. CHILDHOOD, DEVELOPMENTAL, AND LEARNING HISTORY
1. BIRTH COMPLICATIONS: Please explain if there were any complicaticating factors when your
mother was pregnant with you (e.g. drug, alcohol, or tobacco use while pregnant, premature
delivery, low birth weight, seizures, high blood sugar, high blood pressure, mother had multiple
medical problems or needed extended hospitalization). Write NONE if there were no issues:
2. DEVELOPMENTAL HISTORY:
❏ Place an X next to this statement if you have had no delayed milestones and skip this section.
Place an X next to any delayed or absent developmental milestones.
❏ Coordination
❏ Manipulation of objects
❏ Handwriting
❏ Fine motor function
❏ Postural control
❏ Balance
❏ Sensory modulation or integration
❏ Vision perception or processing
❏ Auditory Processing
❏ Hearing
❏ General strength
❏ Endurance
❏ Learning to ride a bicycle
❏ Hand strength
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❏ Not eating solids by 6 months
❏ Not sitting alone by 7 months
❏ Not babbling by 9 months
❏ Not crawling by 10 months
❏ Not self feeding by 11 months
❏ Not standing alone by 12 months
❏ Not speaking a first word by age 1
❏ Not walking by 15 months
❏ Not speaking sentences by age 2
❏ Not using the toilet when awake by age 3
❏
Not staying dry at night by age 5
❏ Social interaction at any age
❏ Dressing or bathing by age 5
❏ Engaging in risky behaviors
3. LANGUAGE
My primary language is
❏ English
❏ Spanish
❏ American Sign Language
❏ Other:
I have been exposed to the English language since
❏ Birth
❏ Over 5 years ago
❏ 4-5 years ago
❏ 1-3 years ago
I have been speaking the English language since
❏ Preschool
❏ Over 5 years ago
❏ 4-5 years ago
❏ 1-3 years ago
❏ I do not speak English
If we do not have someone who speaks your language, will you need translation services?
❏ Yes
❏ No
4. EDUCATION
a. What is the name of your current or most recent school?
b. What is your current, highest grade level, or highest degree or field of study completed?
c.
If applicable, when and why did you stop school?
d. Do or did you frequently change schools and if so, why?
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e. Have you ever been held back or repeated a grade and if so, why?
f.
Have you ever been diagnosed with or suspect you had a learning difficulty? If yes,
please explain:
g. Do you have a 504 plan, IEP, or special education? If so, explain which, what years it is
active, and what it is for.
h. Standardized test performance in Math:
i.
j.
❏ Above average
❏ Average
❏ Below average
❏ Does not apply
Standardized test performance in Reading:
❏ Above average
❏ Average
❏ Below average
❏ Does not apply
Standardized test performance in Language:
❏ Above average
❏ Average
❏ Below average
❏ Does not apply
k.
What are/were your 3 favorite school subjects?
l.
What are/were your grades like?
m. Do/did you like or dislike going to school?
n. Please mark an X next to the statement that best describes your behavior in school:
❏ Excellent student
❏ Liked/likes school
❏ Dislikes school
❏ Frequently in trouble
o. Please mark an X next to the statement that best describes your attendance:
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❏ Perfect
❏ Misses few days
❏ Misses many days
❏ Misses most days
❏ Truancy risk
❏ Truancy court
p. Please mark an X next to the statement that best describes your school discipline history:
❏ Detentions
❏ Expulsions
❏ Suspensions
❏ None
H. FAMILY HISTORY
For the following biological (blood related) relatives, please indicate any medical, substance use,
behavioral and psychiatric disorders they have or had. If they have passed away, please write their cause
of death. This helps us understand your genetic and environmental vulnerabilities. If you do not know their
medical history, please write “Unknown.”
1. Biological mother:
2. Biological father:
3. Maternal Grandmother (your mother's mother):
4. Maternal Grandfather (your mother's father):
5. Paternal Grandmother (your father's mother):
6. Paternal Grandfather (your father's father):
7. Siblings (please indicate if they have the same parents or a different mother or father):
8. Children (please indicate the child’s sex):
Thank you. This concludes the questionnaire. Please ensure you return it directly to a Welcome
Center Staff Member at your local Community Behavioral Health or scan and e-mail this to
intake@communitybehavioralhealth.net along with a copy of your ID and insurance card.
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