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1479 Brockett Rd. Suite 101, Tucker, GA 30084
O: 1-833-5UFIRST | 1-833-583-4778 | F: 1-833-583-4778 www.ufirsthealthcare.org | info@ufirsthealthcare.org


Client Confidential Information Form


Insurance Information


Please attach a copy of your state picture identification AND a copy of your insurance card here. If not,
please attach under the messaging tab in the Patient Ally Portal, via our secure email address at: info@ufirsthealthcare.org OR attach under the Book Appointment tab on our web site at :www.ufirsthealthcare.org for any difficulties, please call our office: 833-583-4778.

INSURANCE AUTHORIZATION AND ASSIGNMENT: I understand that I am responsible for all charges ncurred by me and all charges not allowed by my insurance company. I authorize the release of medical information necessary to process my claims. I authorize payment of any assigned medical benefits to my provider directly.


Signature:

Legal Representative of Patient


Client History


Chief Complaint:


Please list ALL allergies to medications , foods and environment below:


Substance use:


Family History:


Family Dynamic:


Symptoms checklist: What do you have difficulty with?


Consent for Treatment| Authorization| Information


Tele-mental Health Services


Client Signature:_
Client Signature:_

FINANCIAL AGREEMENT


For Disclosure of Mental Health Treatment Information


Sign Here
Signature of Staff Witness :

NOTICE OF PRIVACY PRACTICES


INFORMED CONSENT FOR MEDICATION


Sign Here

MEDICAL / PSYCHIATRY FOLLOW UP VISITS :


Prescribing providers provide prescriptions for medications during appointments. They will rarely
approve refill requests from patients or pharmacies outside of an appointment.
This practice:

• reduces prescription errors
• improves patient safety and
• encourages appropriate follow-up.


It also improves compliance with state laws governing controlled substances.


Patients receive enough medication or refills to last until their next recommended follow-up. It is
therefore important to make and comply with follow-up appointments.


Please be proactive in your care and track how much medication you have and how many refills remain
on your prescription., and ensure you have an appointment to see the doctor before you run out of
medication.


In instances of emergencies, a fee applies when a patient needs a between-visits refill.

• I understand that I may refuse medication(s) unless the refusal would be unsafe to me/my child or
others.
• Many psychiatric medications can cause sensitivity to sunlight or decrease the body’s ability to handle
heat when being used. Using sunscreen when outdoors and drinking fluids when sweating or in hot
settings is good practice on or off medications.
• If there are questions about other potential side effects, I know I can contact the prescribing physician. •
I understand the potential benefits, side effects, and alternatives and I agree to the medication treatment
recommended.
Please print, date, and sign your name below indicating that you have read and understand the contents
of this form, you agree to the policies of your relationship with your provider, and you are authorizing
your clinician to begin treatment with you. By signing this you also agree to undergo mental health
treatment and understand that you can end treatment at any time. It should be discussed with your
physician, but you always reserve the right to stop treatment.


Signature of Guardian, Parent, Personal Representative: describe your authority to act for this individual (power of attorney, healthcare surrogate, guardian, etc.)
Signature of Guardian, Parent, Personal Representative: describe your authority to act for this individual (power of attorney, healthcare surrogate, guardian, etc.)

CREDIT CARD “ON FILE ” AUTHORIZATION FORM

U-First Healthcare, LLC is authorized to maintain credit card payment information in my confidential file. This permits U-First Healthcare, LLC to charge for upcoming treatment sessions and missed appointments. Your signature authorizes UFHC to review this information and deduct fees from the credit card below.

Should the credit card decline, an additional fee to the outstanding balance of $15.00. It is the patient’s responsibility to provide Renewed Journey with new payment information within 24 hours of card declination for the full amount due to avoid future appointments being canceled.


*Most HSAs prohibit missed appointment fees to be accepted. If audited, you will be expected to reimburse your HSA plan directly.

Permission granted to maintain my credit card information on file and automatically charge my credit card when payments are due. I agree that I will pay for this purchase in accordance with the issuing bank card holder agreement.


Sign Here

CONSENT & AUTHORIZATION TO RELEASE INFORMATION


If there are other parties that may assist in your therapy, and you believe it would be helpful for your therapist to contact them regarding your treatment, please read carefully and complete this document.
The following is an authorization for the stated parties to consult with one another regarding your treatment process. Information shared is for the sole purpose of facilitating maximum care to you as the client. Please provide the
necessary information and your signature with today’s date as indicated below.
*******************************************************************************************


(client), hereby authorize U-First Healthcare and the following party or parties to discuss my mental health treatment information and records obtained in the course of psychotherapy treatment, including, but not limited to, therapist’s diagnosis:


Please note that treatment is not conditioned upon your signing this authorization, and you have the right to refuse to sign this form. Please indicate your preference regarding the information to be shared:


Additionally, the above-named parties, therapist & person(s) or entity (entities) designated under (1) or (2), agree to exchange information only between themselves (or their agents). Any disclosure of information extended beyond these< parties is considered a breach of confidentiality.

Your signature below indicates that you understand that you have a right to receive a copy of this authorization. Your signature also indicates that you are aware that any cancellation or modification of this authorization must be in writing, and you have the right to revoke this authorization at any time unless the therapist stated above has taken action in reliance upon it. Additionally, if you decide to revoke this authorization, such revocation must be in writing and received by U-First Healthcare at 1479 Brockett Road Suite 101 Tucker, GA 30084 to go into effect.


Sign Here
Sign Here

Patient Health Questionnaire (PHQ-9)


Important Notice: The information gathered on this questionnaire will remain confidential.


PHQ-9


Over the last two weeks, how often have you been bothered by the following problems?


Generalized Anxiety Disorder 7-item (GAD-7)


Over the last 2 weeks how often have you been bothered by the following problems?


COLUMBIA-SUICIDE SEVERITY RATING SCALE

Screen Version


SUICIDE IDEATION DEFINITIONS AND PROMPTS

Ask questions that are bolded and underlined.                Yes/No

 

Ask Questions 1 and 2

1) Wish to be Dead:

Person endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.


2) Suicidal Thoughts:

General non-specific thoughts of wanting to end one’s life/commit suicide, “I’ve thought about killing myself” without general thoughts of ways to kill oneself/associated methods, intent, or plan.


If YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6

3) Suicidal Thoughts with Method (without Specific Plan or Intent to Act):
Person endorses thoughts of suicide and has thought of a least one method during the assessment period. This is different than a specific plan with time, place or method details worked out. “I thought about taking an overdose but I never made a specific plan as to when where or how I would actually do it….and I would never go through with it.”


4) Suicidal Intent (without Specific Plan):
Active suicidal thoughts of killing oneself and patient reports having some intent to act on such thoughts, as opposed to “I have the thoughts but I definitely will not do anything about them.”


ADHD Assessment for Children


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