test form

All Client Header Client Information

Step 1 Client Registration and Service Selection

Step 2 Preliminary Behavioral Health Screening

Step 3 Consent for Treatment and Service Participation

Step 4 Client Rights, Responsibilities, and Grievance Acknowledgment

Step 5 Freedom of Choice Acknowledgment

Step 6 HIPAA Notice of Privacy Practices Acknowledgment

Step 7 Authorization for Release of Information and Care Coordination

Step 8 Communication, Text, Email, Voicemail, and Electronic Signature Consent

Step 9 EHR, Client Portal, and AI-Assisted Documentation Consent

Step 10 Consent to Bill Insurance, Assignment of Benefits, and Financial Responsibility.

Step 11 Insurance Change and Eligibility Responsibility Policy

Step 12 Attendance, No-Show, Cancellation, and Discharge Policy

Step 13 Telehealth Consent

Step 14 Medication Management Consent

Step 15 Prescription History and Medication Coordination Authorization

Step 16 PRP Participation Agreement

Step 17 Transportation, Community Activities, and Outings Consent

Step 18 Photography and Media Release

Step 19 Crisis, Emergency, Mandatory Reporting, and Limits of Confidentiality Acknowledgment

Step 20 Psychiatric Advance Directive / Mental Health Advance Directive Acknowledgment

Step 21 Maryland Medicaid / Carelon / Data Warehouse and Information Sharing Acknowledgment

Step 22 Prior Services / Discharge Attestation and Duplicate Services Authorization

Step 23 Substance Use Disorder Treatment Consent

Step 24 42 CFR Part 2 Consent and Notice for SUD Records

Step 25 SUD Group Confidentiality and Participation Agreement

Step 26 Urine Drug Screening Consent

Step 27 Final Client Handbook and Packet Acknowledgment

Client First name *

Client Last name *

Date of Birth *

Date

Preferred Name

Legal First name

Legal Middle name

Legal Last name

Preferred First name

Preferred Last name

Date of Birth

Pronouns

Address

Street address

Address line 2

City

State

ZIP Code

Phone Number

Medicaid/Insurance ID

MCO/Insurance Plan

Emergency First name

Emergency Last name

Emergency Contact Phone

Requested Services (check all that apply):

Individual Therapy

Family Therapy

Medication Management

PRP Adult

PRP Youth

SUD IOP

SUD OP

Care Coordination

Residential/Recovery Housing Support

Unsure / Need Screening

Client Signature

Parent/Guardian Signature (if applicable):

Staff/Witness Signature

Purpose: This brief screening helps Breathe Freely determine the most appropriate service pathway. It is not a full diagnostic assessment.

What brings you to services today?

Current concerns (check all that apply):

Depression

Anxiety

Panic

Trauma/PTSD

Grief

Anger

Family conflict

School/work concerns

Substance use

Housing concerns

Medication concerns

Other...

Have you received mental health treatment before?

Yes

If yes, where/when:

Have you ever been hospitalized for mental health concerns?

Yes

Approximate Date

Are you currently taking psychiatric medication?

Yes

Please list:

In the past 30 days, have you experienced:

Sadness

Hopelessness

Anxiety

Sleep problems

Mood swings

Irritability

Hallucinations

Paranoia

None

Have you used alcohol or drugs in the past 30 days?

Yes

Have you ever received substance use treatment?

Yes

Do you currently have thoughts of harming yourself?

Yes

Have you had thoughts of harming yourself in the past 30 days?

Yes

Have you ever attempted suicide?

Yes

Do you currently have thoughts of harming someone else?

Yes

Do you feel safe where you live?

Yes

What is your primary goal for treatment?

If any immediate safety concern is identified, the client may be asked to complete an immediate clinical review, safety plan, crisis referral, or emergency evaluation before routine enrollment proceeds.

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I voluntarily consent to receive services from Breathe Freely Behavioral Health Systems. Services may include assessment, treatment planning, individual/family/group therapy, PRP, medication management, SUD treatment, case management, care coordination, telehealth, and referrals as clinically appropriate.
I understand that participation in treatment is voluntary unless otherwise required by court, probation, child welfare, or another external entity. I understand that outcomes are not guaranteed.
I understand that Breathe Freely may coordinate care with authorized providers, payers, and systems as allowed by my signed authorizations and applicable law.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I understand that I have the right to respectful care, privacy, participation in treatment planning, information about services, access to grievance procedures, and services free from discrimination or retaliation.
I understand that I am responsible for providing accurate information, attending appointments, communicating changes, participating in treatment planning, treating others respectfully, and following program expectations.
I understand that I may file a grievance or complaint without retaliation. I may request assistance from staff to complete the grievance process.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature

I understand that I have the right to choose my behavioral health provider. I acknowledge that I was not forced, pressured, or offered improper incentives to select Breathe Freely Behavioral Health Systems. I understand that other providers may be available.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I acknowledge that I have been offered or provided Breathe Freely Behavioral Health Systems’ Notice of Privacy Practices. This notice explains how my protected health information may be used and disclosed for treatment, payment, and health care operations, and explains my rights regarding my health information.
I understand that Breathe Freely may use and disclose health information as permitted or required by law, including for treatment, payment, health care operations, compliance, reporting, and safety purposes.

HIPAA Notice of Privacy Practices Acknowledgment distribution method:

I received a copy.

I was offered a copy and declined.

I request a copy by email.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I authorize Breathe Freely Behavioral Health Systems to exchange information with the person/entity listed below for the purpose selected. This form should be completed separately for each provider or entity when possible.

First name

Last name

Entity

Phone Number

Fax Number

Information to disclose

Assessment

Treatment plan

Progress/attendance

Medication information

Discharge summary

Billing/eligibility

Other

Purpose:

Treatment coordination

Payment/authorization

Referral/discharge planning

Legal/court/probation

Other

Expiration date/event:

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I authorize Breathe Freely Behavioral Health Systems to contact me using the methods selected below. I understand that text and email may have privacy risks and may not be appropriate for emergencies.

Text message appointment reminders

Email appointment reminders and documents

Voicemail messages with limited information

Electronic signatures on forms and treatment documents

Secure portal messages

Preferred email for signed copy of forms:

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

Breathe Freely uses an electronic health record and/or client portal to maintain records, obtain electronic signatures, store documentation, communicate securely, and support treatment, payment, and health care operations.
Breathe Freely may use AI-assisted tools for documentation support, summaries, administrative support, draft treatment planning assistance, quality review, or workflow efficiency. AI does not provide treatment, make clinical decisions, replace professional judgment, or independently determine diagnosis or services. Documentation must be reviewed and approved by qualified staff before it becomes part of the official record.
I understand that my information will be protected according to applicable privacy laws and agency safeguards. No electronic system can guarantee absolute security.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I authorize Breathe Freely Behavioral Health Systems to bill Medicaid, my managed care organization, insurance plan, or other payer for covered services provided to me or my child. I authorize payment of benefits directly to Breathe Freely for covered services.
I understand that claims may be submitted, corrected, resubmitted, appealed, or adjusted as needed for payment and compliance. I agree to provide accurate insurance information.
I understand that if services are not covered because of inactive insurance, inaccurate insurance information, loss of eligibility, non-covered services, or failure to provide updated insurance information, I may be responsible for charges to the extent permitted by law and payer rules.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I understand that I must notify Breathe Freely immediately if my Medicaid, MCO, private insurance, address, phone number, or eligibility changes. I understand that services billed under inactive or incorrect insurance may be denied.
I agree to provide updated insurance cards, Medicaid/MCO information, and any notices of eligibility changes as soon as I receive them.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

Consistent attendance is necessary for effective treatment and continued enrollment. I agree to attend scheduled appointments and to notify Breathe Freely as soon as possible if I need to cancel or reschedule.
I understand that two or more missed appointments, repeated cancellations, failure to communicate, or failure to participate may result in removal from a recurring appointment slot, inactive status, reassessment, transfer, discharge, or referral to another level of care, at the discretion of the agency and consistent with clinical and payer requirements.
I understand that medication appointments are important and that missed medication appointments may delay refills or require provider review before medication changes or refills occur.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I consent to receive services by telehealth when clinically appropriate. Telehealth may include video, telephone, or secure electronic platforms.

Technology may fail or be interrupted.
I must be in a private and safe location during sessions.
Telehealth may not be appropriate for every situation.
In an emergency, I should call 911, 988, or go to the nearest emergency room.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I consent to psychiatric/medication management services from Breathe Freely Behavioral Health Systems. I understand that services may include psychiatric evaluation, medication recommendations, prescriptions, medication education, monitoring, and coordination with pharmacies or other providers.

Medication may have risks, benefits, side effects, interactions, and alternatives.
I agree to take medication only as prescribed and to ask questions if I do not understand instructions.
I will report side effects, allergies, pregnancy, medication changes, substance use, or medical changes.
I understand that medication management does not replace emergency care.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I authorize Breathe Freely providers, as permitted by law, to review pharmacy/prescription history, medication lists, lab information, and relevant medical records to support safe prescribing and care coordination.
I authorize communication with my pharmacy, primary care provider, specialists, hospitals, and other prescribers as needed for medication safety and coordination.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I understand that PRP services are rehabilitative services designed to help me build skills, improve functioning, and work toward goals identified in my Individual Rehabilitation Plan.

I agree to participate in scheduled PRP visits and activities.
I understand that PRP is not a substitute for therapy or medication management.
I understand that PRP requires ongoing collaboration with treatment providers.
I understand that missed appointments or lack of participation may affect continued eligibility.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I consent to transportation and/or participation in community-based activities when offered by Breathe Freely Behavioral Health Systems. Transportation may be provided by agency staff, contracted transportation, public transportation coordination, or approved community resources.

Transportation is provided as a support and convenience when available; it is not guaranteed.
Seatbelts must be worn. Unsafe or inappropriate behavior may result in loss of transportation privileges.
Breathe Freely is not responsible for personal items lost, stolen, or left in vehicles or activity locations.
I understand that ordinary risks may occur during transportation and community activities. In an emergency, staff may contact emergency services and my emergency contact.
This consent does not waive rights that cannot legally be waived, but I understand the agency is not liable for circumstances outside its control.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

Please select one option:

I allow Breathe Freely to use photos/videos of me/my child for agency events, newsletters, website, social media, or promotional materials.

Internal use only: photos/videos may be used only for documentation, internal files, or non-public agency purposes.

No media permission: I do not allow photos/videos to be used except as required for clinical documentation or safety purposes.

I understand I may revoke media permission in writing for future use, but materials already published may not be fully retractable.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I understand that services are confidential, but confidentiality has limits. Breathe Freely may disclose information without my authorization when required or permitted by law, including but not limited to suspected abuse or neglect, threats of serious harm to self or others, medical emergencies, court orders, audits, licensing reviews, and other legally required situations.
I understand that Breathe Freely is not an emergency response provider. In a crisis, I should call 988, 911, mobile crisis services, or go to the nearest emergency department.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

A Psychiatric Advance Directive or Mental Health Advance Directive allows a person to document preferences for future mental health care and identify someone to help make decisions if the person becomes unable to make or communicate decisions during a crisis.

Please select one:

I have a Psychiatric/Mental Health Advance Directive and will provide a copy.

I do not have a Psychiatric/Mental Health Advance Directive.

I would like information about creating one.

I decline information at this time.

Client Initials:

Signature

I understand that Breathe Freely may submit information related to my services to Maryland Medicaid, managed care organizations, the behavioral health administrative services organization, Carelon Behavioral Health of Maryland, health information systems, authorization portals, billing systems, quality review systems, and other approved entities as needed for treatment, payment, healthcare operations, authorizations, claims, compliance, quality improvement, and care coordination.
This may include demographic information, eligibility, diagnoses, service dates, authorizations, claims, provider information, treatment-related information, and outcome or utilization information as permitted or required by law.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I understand that Medicaid and payer rules may not allow duplicate services from multiple agencies at the same time. I agree to disclose all current services and providers.

I am not currently receiving the same service from another agency.

I may still be open with another provider and authorize Breathe Freely to verify and coordinate closure/transfer.

I am currently receiving services elsewhere and understand Breathe Freely may need confirmation of discharge or transfer before starting duplicate services.

Current/previous providers:

I authorize Breathe Freely to verify enrollment status, coordinate transition/discharge, request records, and proceed with enrollment once eligibility and service duplication issues are resolved.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I consent to receive substance use disorder services from Breathe Freely Behavioral Health Systems. Services may include assessment, ASAM level-of-care review, IOP, OP, individual counseling, group counseling, recovery planning, case management, relapse prevention, drug screening, discharge planning, and care coordination.
I understand that participation, attendance, honesty regarding substance use, and engagement in recovery planning are important parts of treatment.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I understand that substance use disorder records may receive additional confidentiality protections under federal law, including 42 CFR Part 2. I authorize Breathe Freely to use and disclose SUD-related information for treatment, payment, and health care operations when permitted by my consent and applicable law.
Recipients may include treating providers, Medicaid/MCOs, Carelon/ASO systems, pharmacies, laboratories, hospitals, referral providers, care coordinators, auditors, and other entities involved in treatment, payment, health care operations, or compliance as permitted by law and the scope of this consent.
I understand that I may revoke this consent in writing except to the extent action has already been taken in reliance on it. I understand I may request a more limited consent, but limitations may affect services, payment, or coordination.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I understand that group treatment depends on respect and confidentiality. I agree not to disclose the identity, personal information, or treatment information of other group members outside the group.

I will participate respectfully and avoid disruptive, threatening, discriminatory, or harassing behavior.
I understand that Breathe Freely staff will protect confidentiality, but cannot guarantee that other group members will do the same.
I understand that intoxication, unsafe behavior, repeated disruption, or violation of confidentiality may result in removal from group or reassessment.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I consent to urine drug screening, breath testing, or other clinically appropriate toxicology screening when required for assessment, treatment planning, monitoring, payer requirements, referral coordination, or program compliance.
I understand that refusal to test, tampering, missed testing, or concerning results may affect treatment planning, level-of-care recommendations, program participation, or referrals.

Client Initials:

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

I acknowledge that I have reviewed, received, or been offered copies of the forms and policies in this packet. I had an opportunity to ask questions. I understand that I may request another copy of signed forms and agency policies.

Forms completed today (check all that apply):

1. Client Registration and Service Selection

2. Preliminary Behavioral Health Screening

3. Consent for Treatment and Service Participation

4. Client Rights, Responsibilities, and Grievance Acknowledgment

5. Freedom of Choice Acknowledgment

6. HIPAA Notice of Privacy Practices Acknowledgment

7. Authorization for Release of Information and Care Coordination

8. Communication, Text, Email, Voicemail, and Electronic Signature Consent

9. EHR, Client Portal, and AI-Assisted Documentation Consent

10. Consent to Bill Insurance, Assignment of Benefits, and Financial Responsibility

11. Insurance Change and Eligibility Responsibility Policy

12. Attendance, No-Show, Cancellation, and Discharge Policy

13. Telehealth Consent

14. Medication Management Consent

15. Prescription History and Medication Coordination Authorization

16. PRP Participation Agreement

17. Transportation, Community Activities, and Outings Consent

18. Photography and Media Release

19. Crisis, Emergency, Mandatory Reporting, and Limits of Confidentiality Acknowledgment

20. Psychiatric Advance Directive / Mental Health Advance Directive Acknowledgment

21. Maryland Medicaid / Carelon / Data Warehouse and Information Sharing Acknowledgment

22. Prior Services / Discharge Attestation and Duplicate Services Authorization

23. SUD Treatment Consent

24. 42 CFR Part 2 Consent and Notice for SUD Records

25. SUD Group Confidentiality and Participation Agreement

26. Urine Drug Screening Consent

27. Final Client Handbook and Packet Acknowledgment

Copy Delivery:

Email copy to client/guardian

Print copy provided

Client declined copy

Client Signature:

Parent/Guardian Signature (if applicable):

Staff/Witness Signature:

Please note that your information is saved on our server as you enter it.

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