test form

Client Registration Client Information

Step 2 Client Registration and Service Selection

Step 3 Preliminary Behavioral Health Screening

Step 4 Consent for Treatment and Service Participation

Step 5 Client Rights, Responsibilities, and Grievance Acknowledgment

Step 6 Freedom of Choice Acknowledgment

Step 7 HIPAA Notice of Privacy Practices Acknowledgment

Step 8 Authorization for Release of Information and Care Coordination

Step 9 Communication, Text, Email, Voicemail, and Electronic Signature Consent

Step 10 EHR, Client Portal, and AI-Assisted Documentation Consent

Step 11 Consent to Bill Insurance, Assignment of Benefits, and Financial Responsibility.

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.

Check Boxs

Option 1

Option 2

Option 3

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:

Client Initials:

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 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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