CHE FACILITY PATIENT INTAKE FORM
CONSENT FOR TREATMENT
I consent to CHE Behavioral Health's provision of counseling, psychological, psychiatric, or other behavioral health services. I
understand that behavioral health treatment may result in unexpected side effects, such as intense or uncomfortable
emotions, and that it is important that I discuss any reactions to my treatment with my treating clinician. Behavioral health
treatment can also provide benefits, such as a significant reduction in feelings of stress and improved self-esteem. I am
aware, however, that no guarantees have been made to me about the results of services. Some alternatives to behavioral
health treatment include peer self-help groups, support groups, 12-step programs, and other similar programs.
CONSENT TO TREATMENT VIA TELEHEALTH
I consent to participate in telemental health services. I understand that I have the right to refuse telemental health services
and be informed of alternative services that may be available to me. If I request alternative services, CHE Behavioral Health
will inform me of any resulting delays in service, the need to travel, or any other risks associated with not having services
provided via telemental health, and risks associated with receiving telemental health services in an off-site location. I
understand that telehealth may result in certain risks that are less likely to occur with in-person services, such as technology
failure, need for specialized electronic security systems, and less visibility of verbal cues. Telehealth can also provide benefits
not present with in-person services, such as creating greater flexibility for when and where services may be provided. My
telemental health session(s) will not be recorded without my express consent.
RELEASE OF INFORMATION
I authorize CHE Behavioral Health to release medical records, financial and other health information about me as described in
CHE Behavioral Health's Notice of Privacy Practices, a copy of which I have received. I acknowledge and understand that CHE
Behavioral Health can release my information to (a) government programs, third party insurance carriers, health service plans,
health maintenance organizations, or third party administrators for payment purposes; (b) to health care providers (including
my designated primary care provider) for my continuing patient care and other related purposes; and (c) to caregivers,
including but not limited to family members.
FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS
I agree that I am financially responsible for all charges related to services provided by CHE Behavioral Health. Third-party
payers (including, as applicable, government programs such as Medicare and Medicaid) may make payments directly to CHE
Behavioral Health. My signature on this form is my authorized signature for the filing of a claim and request for direct payment
of benefits by any such payer to CHE Behavioral Health. I agree that unless CHE Behavioral Health or my attending health
care provider have expressly agreed in writing with the third-party payer to accept payment from the payer as full payment, I
am personally responsible to pay any charges not paid by the payer. These charges can include but are not limited to copays, deductibles, co-insurance amounts, and charges for non-covered services.
PRIOR EXPRESS CONSENT FOR TELEPHONE, SMS OR EMAIL CONTACT
I agree CHE Behavioral Health, or its third party vendor, may contact me by telephone at any telephone number associated with my
account, including wireless telephone numbers. I also agree that if I have provided CHE Behavioral Health with an e-mail address or
telephone number for a cellular phone or other wireless device, CHE Behavioral Health may contact me by text message or e-mail.
This express consent applies to each such e-mail address or telephone number I provide CHE Behavioral Health now or in the
future and permits such calls, texts and e-mails regardless of their purpose. I understand that calls and messages may incur access
fees from my cellular provider.
I have read the information above, and have had the opportunity to ask questions and have them answered to my satisfaction. I
further acknowledge that I have received CHE Behavioral Health's Notice of Privacy Practices. If I am not the patient identified on
this form, I represent that I am authorized by law to agree to these conditions on the patient's behalf and am the authorized
representative of the patient. A copy of this form is as effective and valid as the original.