Adult Behavioral Health Intake

Full Legal Name*
Date of Birth*
Address*
Marital Status*
Employment*
Are you the insurance policyholder? *
Policy Holder Name*
Policy Holder Date of Birth*

Emergency Contact

Emergency Contact*
Address
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Are you interested in Medication-Assisted Treatment (MAT)? (Suboxone, Subutex, Vivitrol)*

MAT Intake

Devaraj Behavioral Healthcare Policies

Please indicate that you have read and understood the above policies by selecting the check mark below each policy. 

Our practice is limited to outpatient treatment. If a patient requires admission, we may attempt to make arrangements for the admission to the best of our ability and will collaborate with attending psychiatrists at the hospitals in the region and aid with the treatment decisions. *

Financial Policy

We are committed to providing you with the best possible care and we are pleased to discuss our office policies with you at any time. Understanding our office policies is important to our relationship. Please ask if you have any questions about our fees, financial policy, or our responsibility. We accept cash, money orders, and credit cards (please note that a card fee may apply). Full payment is due at the time treatment is rendered. All accounts that are outstanding for more than 90 days will be sent to our collection agency.*

Insurance Policy

We accept some but not all insurances for Medication assisted treatment. If insurances reject claims and/or deductibles are not met by the patient for their particular insurance, patients will be responsible for the payment for services rendered. *

Appointment Policy

If you are more than 10 minutes late for your scheduled appointment, we may ask you to reschedule. A cancelled appointment with a 24-hour notice may be rescheduled. A cancellation without a 24-hour notice will result in a fee equivalent to half the amount of the normal visit rate. A NO SHOW without calling to cancel will result in fee equivalent to the full amount of the normal visit rate. Services may be terminated for multiple cancellations.*

Emergency Care Policy

If you have a medical or psychiatric emergency either call 911 or go directly to the Emergency Room before trying to contact our office. Since the office is not equipped to deal with emergencies we will most likely direct you to the ER if such circumstances, so calling our office first would only be wasting valuable time. We will however do our best to aid you in a psychiatric emergency when you get to or are en route to an appropriate emergency treatment facility. Our office can be reached at (877) 338-2725. If unavailable at the time of your call, leave a message on voicemail with your name, telephone number and the reason for the call. Someone will call you back as soon as possible.*

Payment Policy

  • Initial Psychiatric and Physical Examination/M.D. evaluation $330.00
  • Medication review/management $110.00
  • Urine Drug Screen $75.00
  • Telephone consult $110.00
  • No Show is Full charge $110.00

Please note: telephone consult, cancellation, no show and refill charges are not usually reimbursable by insurance companies. 

Devaraj Behavioral Healthcare has established the above payment policies for private pay patients. *
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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. The privacy of your health information is very important to us and we want to do everything possible to protect that privacy. We have an ethical and a legal responsibility under federal and state law to keep your health information private. Part of our responsibility is to give you this notice about our privacy practices. Another part of our responsibility is to follow the practices in this notice. Please feel free to ask for clarification about anything in this material.

Here are some examples of how we use and disclose information about your health:

We may use or disclose your health information to:

1. Any one of our staff involved in your treatment program. This includes paid, volunteer, intern, clinical, or administrative staff, on a need to know basis. We may contact you for the purpose of setting up appointments, appointment reminders, and to provide you with treatment alternative and health-related information.

2. Set-up and receive payment from you or from a third-party payer (such as your insurance) for services we provide for you.

3. We also may disclose your health information to a physician or other healthcare provider who is also treating you.

4. Professional business associates, such as a contracted medical billing agency. Our business associates are expected and required to protect and safeguard our information with the highest professional standards.

5. Anyone you give us written authorization to have your protected health information, for any reason you want. You may revoke this authorization in writing at any time. When you revoke an authorization, it will only affect the disclosure of your health information from that point on.

6. A family member, person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, we will give you an opportunity to object. If you object, or are not present, or are incapable of responding, we may use our professional judgment, in light of the nature of the emergency to use or disclose your health information in your best interest at the time. In so doing, we will only use or disclose the aspects of your health information that are necessary to respond to the emergency.

7. Avoid harm or if you are a danger to yourself or others. We may provide your health information to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public. Disclosure is compelled or permitted if you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if we determine that disclosure is necessary to prevent a threatened danger. Disclosure is mandated, if we have a reasonable suspicion of child abuse or neglect, or if we have a reasonable suspicion of elder abuse or dependent adult abuse or neglect. Disclosure is compelled or permitted by us if you tell us of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.

8. Any person required by federal, state, or local laws to have lawful access to your treatment program. These may include, but are not limited to, circumstances involving clients who are military personnel, cases involving worker compensation, or if there is a possibility of a public health risk.

We will not use or disclose your health information in any way other than those described in this notice unless you give us written permission.

Important rights you have as a client:

As a client, you have these important rights:

A. With limited exceptions, you can make a written request to inspect your protected health information. You may request paper copies of this information. There is a $0.25 per page fee for making these copies.

B. You have a right to a copy of this notice at no charge.

C. You can make a written request to have us communicate with you about your health information by alternative means, such as by fax only, or at an alternative location, such as to your workplace only. Your written request must specify the alternative means and location.

D. You can make a written request that we place other restrictions on the ways we use or disclose your health information. We may deny any or all of your requested restrictions. If we agree to these restrictions, we will abide by them in all situations except those which, in our professional judgment, constitute an emergency.

E. You can make a written request that we amend any part of your health information. If we approve your written amendment, we will change or make addendums to our records accordingly. We will also notify anyone else who may have received this information, and anyone else of your choosing. If we deny your amendment, we will do so in writing. You can place a written statement in our records disagreeing with our denial of your request.

F. You may make a written request that we provide you with a list of occasions where we or our business associates disclosed your health information for purposes other than for treatment, payment, or operations. If you request this more than once in a twelve-month period, we may charge you a fee based on our costs for preparing these disclosures.

G. If you believe we have violated any of your privacy rights, or you disagree with a decision we have made about any of your rights in this notice, you may submit a written complaint to us or the United States Department of Health and Human Services. We shall provide you with that address upon written request.

We reserve the right to modify/update any of these privacy practices as permitted or required by law. Any modifications/updates to our privacy practices may affect how we protect the privacy of your health information. This includes health information we maintain or have received from external sources. These changes may also affect how we protect the privacy of any of your health information before the changes. If and when any changes are made to our Privacy Practice this document will be updated. You will receive an updated copy of this document if you are an active client at the time of the change or at your request.

If you have any questions or concerns regarding the material in this document, please ask us for assistance.

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Patient/Client Rights

As a patient/client of Devaraj Behavioral Healthcare, you have the right to:

1. Not be unlawfully discriminated against in determining eligibility for a treatment program based on race, creed, sex, economic status, education, religion, gender identity, sexual orientation, and political views.
2. Give informed consent to receive a service.
3. Have input into your treatment and case management plans and be informed of their consent.
4. Receive individualized treatment.
5. File a grievance, recommendation, or opinion regarding the services you receive by calling the Clinical Director or Executive Director.
6. You are assured confidentiality according to West Virginia regulation.
7. Request a written statement of change for a service and be informed by the policy for the intake and counseling and/or the fees.
8. Be informed of the rules of conduct, including the consequences for the use of alcohol and other drugs on the premises or other infractions that may result in disciplinary action or discharge from the program.
9. Be treated with consideration, respect, and personal dignity.
10. Review your records in accordance with agency policy.
11. Be able to make up one session per month that has been missed. This session must be made up within 7 days or termination of services can be initiated.

As a patient getting treatment for a substance use disorder, your personal and medical information is protected under United State Confidentiality law. This law states that your doctor is not allowed to tell anyone the reason you are being treated, without your permission. Doctors and treatment programs that provide addiction treatment are not even allowed to tell anyone whether or not you are a patient.

Patient Consent

With your approval (sometimes called your consent) your doctor may let others, such as your insurance company or your family, know about your treatment. No information will be released unless you sign a consent form, which will include the name of your doctor or treatment provider, the person/group to whom your information is going, the purpose of the disclosure, how much information may be communicated, when the consent form expires, and the date. Even if you sign a consent form, you have the right to change your mind at any time. If you do change your mind, your doctor will not share any additional information with others.

Impact on Treatment:

The confidentially law is strict, but it will not keep you from getting good treatment. Exceptions were written into the law to make sure patients still get excellent care. For instance, information can be shared among treatment staff in order to provide you with better treatment. Also, the law takes into account unexpected things that might happen. For instance, if there is a medical emergency and if they need to know, the medical personnel treating you can be told that you are receiving maintenance treatment for substance use disorder.

The Last Word

Remember, the confidentiality law was set up to protect your rights. Ask your doctor if you have more questions about confidentiality or consent.

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Patient Treatment Contract

As a participant in buprenorphine treatment for opioid misuse and dependence, I freely and voluntarily agree to accept this treatment contract as follows:

1. I agree to keep and be on time to all my scheduled appointments.
2. I agree to adhere to the payment policy outlined by this office.
3. I agree to conduct myself in a courteous manner in the doctor’s office.
4. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.
5. I agree not to deal, steal, or conduct any illegal or disruptive activities in the doctor’s office.
6. I understand that if dealing, stealing or if any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my buprenorphine is filled, that the behavior will be reported to my doctor’s office and could result in my treatment being terminated without any recourse for appeal.
7. I agree that my medication/prescription can only be given to me at my regular office visits. A missed visit may result in my not being able to get my medication/prescription until the next scheduled visit.
8. I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place. I agree that lost medication will not be replaced regardless of why it was lost.
9. I agree not to obtain medications from any doctors, pharmacies, or other sources without telling my treating provider.
10. I understand that mixing buprenorphine with other medications, especially benzodiazepines (for example, Valium®, Klonopin®, or Xanax®), can be dangerous. I also recognize that several deaths have occurred among persons mixing buprenorphine and benzodiazepines (especially if taken outside the care of a treating provider, using routes of administration other than sublingual or in higher than recommended therapeutic doses).
11. I agree to take my medication as instructed and not to alter the way I take my medication without first consulting my treating provider.
12. I understand that medication alone is not sufficient treatment for my condition, and I agree to participate in counseling as discussed and agreed upon with my provider and specified in my treatment plan.
13. I agree to abstain from alcohol, opioids, marijuana, cocaine, and other addictive substances (exempting nicotine).
14. I agree to provide random urine samples and have my doctor test my blood alcohol level.
15. I understand that violations of the above may be grounds for termination of treatment.

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Consent to Invoice

Patient Full Name*
Name on Primary Insured's Health Insurance Card: (you may put N/A if you are the policy holder)*
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Patient Intake: Medical History

Date of last physical *
:  
Have you ever head an EKG?*
When was the date of your last EKG?
:  
Current or past medical conditions (please check all that apply)*
If there is a family history of any of the following illnesses, please check those here. If there is a family history of something not listed, please list that here as well.
Have you ever had surgery or been hospitalized?*
Have you or a family member ever been diagnosed with a psychiatric or mental illness?*
Have you ever taken or been prescribed antidepressants?*

Patient Intake: Medical History

Have you had the following illnesses as a child?*
Have you ever smoked?*
How many per day?

MAT Program

Please indicate past/current use for the following substances. 

Alcohol*
Caffeine (pills or beverage)*
Cocaine *
Methamphetamine*
Heroin*
Inhalants*
LSD or Hallucinogens *
Marijuana *
Methadone*
Painkillers*
PCP*
Stimulants (pills)*
Tranquilizers or sleeping pills *
Ecstasy*
Have you ever been treated for substance use disorder(s)?*
Are you currently enrolled in another Office Based Medication-Assisted Treatment Program?*
Do you have any current or past legal issues?*

Program Policies Regarding Smoking, Firearms, Drugs, and Alcohol

For patients, families of patients, and friends of patients attending Devaraj Behavioral Healthcare:

Smoking is only permitted in designated areas. There shall be no smoking in front of the main doors or on either side of the doors in front of the large windows. Cigarettes should be properly disposed of and not thrown on the ground. Under NO circumstances are firearms of any kind allowed on the premises. No illicit or licit drugs shall brought into the program or onto the premises as it is strictly prohibited. The use of alcohol on or prior to entering the facility is strictly prohibited. Any patients, relatives of patients, or friends of patients violating ANY of these rules will result in dismissal of the patient from the clinic.

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Administrative Withdrawal Policy & Procedures

Administrative withdrawal is an involuntary withdrawal or administrative discharge from this program. The schedule of withdrawal may be brief: less than 30 days, if necessary.

Administrative withdrawal may result from any of the following:

1. Non-payment of fees. We shall make every effort to consider all clinical data, including patient participation and compliance with treatment prior to initiating administrative withdrawal for non-payment. We shall explore alternative to administrative withdrawal with the patient prior to the onset of withdrawal.
2. Disruptive or adverse effect conduct. Disruptive conduct or behavior considered to have an adverse effect on the program, clinical staff or patient population of such gravity as to justify the involuntary withdrawal and discharge of a patient. Such behaviors may include violence, threat of violence, dealing drugs, diversion of pharmacological agents, violation of peer confidentiality, repeated loitering, and failure to follow treatment plan objectives or non-compliance with program rules, policies, and procedures resulting in an observable, negative impact on the program, staff, and other patients. These may result in patient loss of rights to continue as a patient of Devaraj Behavioral Healthcare.
3. Incarceration or other confinement. This program will work with law enforcement and corrections personnel to avoid mandatory withdrawal when possible.
4. This program shall document in the patients individualized plan of care and treatment strategy and chart all efforts regarding referral or transfer of the patient to suitable, alternative treatment.
5. Female patients shall have a negative pregnancy screen prior to the onset of administrative withdrawal.
6. The program shall have in place a detailed relapse prevention plan developed by the counselor in accordance with approved nation guidelines and in conjunction with the patient. The prevention plan shall be given to the patient in writing prior to the administration of the finial dose of medication.

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Drug Testing in Suboxone Treatment in an Outpatient Setting

Drug Testing will be utilized to assure compliance with treatment in the OP Structured Addiction Treatment setting. At screening, all patients will be administered an instant 12 Panel Drug Test. This test is a CLIA Waived Test and will be administered by trained staff members. It is unobserved. The results of the instant test will be recorded and placed in the patient’s chart. If the results are positive for illicit or unapproved prescription drugs or absent of prescribed medication, the patient may be discharged from treatment by the physician or given an order for a “send out”, chain of custody and possible observed test utilizing a SAMSHA approved lab. The patient’s dismissal from treatment may be delated until these results are received. This is at the treating providers discretion. All patients will be tested randomly, no less than monthly. Refusal or inability to test will result in termination from treatment. Patients may be called into the office by the provider for testing at any time. Failure to comply will result in termination from treatment.

Random drug screens will be performed and must be completed within 24-hours of the request at
A. Our clinic.
B. An outside agency with prescription provided by this clinic.

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Important Information for Patients Prescribed Suboxone or Subutex

Use of Benzodiazepines (e.g. Xanax, Klonopin, Valium, and Ativan) or alcohol with Suboxone or Subutex is very dangerous and potentially fatal. Suboxone and Subutex products contain opioid and can be a target for people who abuse prescription medication or street drugs. Please keep your medication safe and protect it from theft. Keep Suboxone and Subutex in a secure place that is out of the sight and reach of children. Accidental or deliberate ingestion of Suboxone or Subutex by a child can result in death. If a child is exposed to Suboxone or Subutex, medical attention should be sought immediately.


Never give your Suboxone or Subutex to anyone else, even if he or she has the same signs or symptoms. It may cause harm or death. Selling or giving away Suboxone or Subutex is against the law.

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Board of Pharmacy Report

The Board of Pharmacy Database is used to ensure patients are compliant with Buprenorphine and to ensure that patients are not being prescribed Buprenorphine by any other providers or participating in any other programs. A Board of Pharmacy report also shows any other controlled substances that are prescribed to the patient. Results obtained from the Board of Pharmacy Database will be kept in patient records.

These results are obtained at:
1. The time of intake.
2. After 30 days in the program.
3. After conformation of a positive Urine Drug Screen.
4. At each 90-day review.

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Environment and Operations

Services will not be interrupted due to staff vacation.

Scheduled Vacation: Provisions will be made to see patients on alternate days and sufficient medication will be provided.

Unscheduled Vacation or emergency closure: Patient will be notified via phone and medications will be called in to the pharmacy until next appointment.

Access of After-Hours Services

Established patients can call 24/7 and leave a voicemail at (877) 338-2725. You will receive a return phone call within 12 hours by a physician or qualified healthcare provider. In the event of an emergency, we encourage you to call 911 or go directly to the Emergency Room. Devaraj Behavioral Healthcare is an outpatient facility that does not have the ability to provide emergency care.
Patients are advised that prescription and dose information can be available 24- hours a day, and 7 days a week by contacting the office or a 24-hour pharmacy that will have access to the Board of Pharmacy webpage.


Regular Hours of Operation

Monday - Friday

9 A.M. - 5 P. M.

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Submission of MAT Intake

I verify all information filled above is correct and ready to be submitted. *

After hitting the "next" button, you will continue filling out the Behavioral Health Intake Form. 

Mental Health Questionnaire

Over the past two weeks, how often have you been bothered by any of the following problems?
Over the past two weeks, how often have you been bothered by any of the following problems?
  Not at all Several days More than half the days Nearly everyday
Feeling nervous, anxious, or on edge
Not being able to sleep or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid, as if something awful might happen
Depressed mood
Loss of interests
Increased/decreased sex drive
Impulsivity/risk taking
Crying spells
Changes in appetite
Excessive energy
Low energy/fatigue
Blackouts or loss of time
Hallucinations/delusions
Excessive guilt
Distrust of others
Using drugs/alcohol
Craving to use drugs/alcohol
Withdrawal from drugs/alcohol
Racing thoughts
Irritability/anger
Decreased need for sleep
Extreme sleepiness
Avoiding problems
Self-harming behavior
Suicidal thoughts or attempts
Legal issues

Medical History

Do you have allergies?*
Do you smoke, chew, or vape nicotine/tobacco products?*
Do you consume alcohol?*
Do you exercise regularly?*
Medical or psychiatric problems that are relevant to you and your family.
Have you been hospitalized for psychiatric reasons?*
Have you ever participated in therapy before?*

Family/Social Background

What is your sexual orientation?*
Are you sexually active?*
Were you adopted?*
Do you have children?*
Do you have siblings?*
Did your parents divorce?*
Relationship with mother*
Relationship with father*
Are you currently homeless?*
Do you have any past or pending legal problems?*
Have you ever been arrested?*

Education/Work Background

Did you graduate high school/receive GED?*
Did you or do you currently attend college?*
Are you a veteran or active duty military personnel?*

Substance Abuse History

How often do you use/take the following?
How often do you use/take the following?
  Sometimes Occasionally Often Never
Alcohol
Opioids/opiates (pills, heroin, fetanyl, etc.)
Marijuana/THC
Benzodiazepines (Xanax, Valium, Ativan, etc.)
Methamphetamines (Meth, ice, speed)
Non-prescribed stimulants (Adderall, Rotalin, Concerta, etc.)
Cocaine
Non-prescribed Methadone or Suboxone (Subutex)
Non-prescribed sleeping pills
Non-prescribed muscle relaxers
LSD/Mushrooms/Ecstasy/DMT
PCP/other hallucinogens
Kratom
Synthetic marijuana
Ketamine/Tranquilizers
Do your friends or family criticize you for drug or alcohol use?*
Have you ever received treatment for drug or alcohol addiction?*
Do you have feelings of guilt about using drugs or alcohol?*
Do you feel like you have a problem with drugs or alcohol (or should cut down)?*

Drug Screening Questionnaire (DAST)

In the past six months, have you ever tried or used any of the following? (Select all that apply)*
How often have you used these drugs *
Have you ever used drugs other than those required for medical reasons?*
Do you abuse more than one drug at a time?*
Are you always able to stop using drugs when you want to?*
Have you ever had blackouts or flashbacks as a result of drug use?*
Do you ever feel guilty about your drug use?*
Does you spouse (or parents) ever complain about your involvement with drugs?*
Have you neglected your family because of your use of drugs?*
Have you engaged in illegal activities in order to obtain drugs?*
Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? *
Have you had medical problems as a result of your drug use? (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)*
Have you ever injected drugs?*
Have you ever been in treatment for substance abuse?*

Alcohol Screening Questionnaire (AUDIT)

Drinking alcohol can affect your health and some medications you may take. Please help us provide you with the best care by answering the questions below. 


                                                      

How often do you have a drink containing alcohol?*
How many drinks containing alcohol do you have on a typical day when you are drinking?*
How often do you have five or more drinks on one occasion?*
How often during the last year have you found that you were not able to stop drinking once you had started?*
How often during the last year have you failed to do what was normally expected of you because of drinking?*
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?*
How often during the last year have you had a feeling of guilt or remorse after drinking?*
How often during the last year have you been unable to remember what happened the night before because of drinking?*
Have you or someone else been injured because of your drinking?*
Has a relative, friend, doctor, or other healthcare worker been concerned about your drinking or suggested you cut down?*
Have you ever been in treatment for an alcohol problem?*

Adverse Childhood Experience (ACE) Questionnaire

While this subject may be sensitive, answering these questions accurately help us to assess and understand your background as a person. Please answer all questions to the best of your ability, your answers are completely confidential. (Questions are from childhood to 18 years of age) 

Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you? OR act in a way that made you afraid that you might be physically hurt?*
Did a parent or other adult in the household often push, grab, slap, or throw something at you? OR ever hit you so hard that you had marks or were injured?*
Did an adult or person at least five years older than you ever touch or fondle you, or have you touch their body in a sexual way? OR try to actually have oral, anal, or vaginal sex with you?*
Did you often feel that no one in your family loved you or thought you were important or special? OR your family didn't look out for each other, feel close to each other, or support each other?*
Did you often feel that you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? OR your parents were too drunk or high to take care of you or take you to the doctor if you needed it?*
Have you witnessed a member of your household being pushed, grabbed, slapped, or had something thrown at them? OR kicked, bitten, hit with a fist, or hit with something hard? OR threatened with a gun or knife?*
Did you live with anyone who was a problem drinker, alcoholic, or used street drugs?*
Was a household member mentally ill or attempt suicide?*
Did a household member go to prison?*

Beck's Depression Inventory

This depression inventory can be self-scored and is meant to assess the current state of/symptoms of depression. 

Please choose one answer*
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Review, Sign, & Submit

By signing, I agree that I (undersigned) have answered the following questions for myself to initiate medical/behavioral health/substance abuse services rendered by licensed, trained professionals affiliated with Devaraj Behavioral Healthcare

Print name*
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Confidentiality & Privacy Policy

All interactions which take place at Devaraj Behavioral Healthcare or rendered by affiliates there of, will remain confidential. This includes requests by telephone, all therapy, recovery coaching, or scheduling notes. All sessions with therapist may be recorded for quality assurance, and/or improving care. In the event of a recording you will be verbally notified by the Therapist/Provider. You may give expressed permission to disclose specific details or general health information to any person or agency you designate. You have the right to withdraw this agreement at anytime, but it should be done so in writing with a 48-hour notice to adequately fulfill the request. By signing below you are agreeing to this policy and the terms of this agreement willfully. (Before signing please review limits to this agreement below):

Limits to this agreement:

1. In some legal proceedings a judge may issue a court order, this would require our providers to provide documentation, records, or possibly testify in court. While our interest is protecting your information, legally binding requests may present a situation which would be out of our control.

2. If any provider or employee learns or has evidence to believe there is physical abuse, sexual abuse, or neglect of any person under 18 years of age, we will report this incident to Child Protective Services and all confidentiality may become null and void depending on context, severity, and form of disclosure.

3. If any provider or employee learns of or has evidence to believe that an elderly, disabled, or incapacitated adult is being abused, exploited, neglected, or harmed, we will report the findings to Adult Protective Services. In the event of this report all confidentiality may become null and void depending on context, severity, and form of disclosure.

4. If any provider or employee has reason to believe that you may be a danger to yourself or others, and believe you are likely to follow through with actions as such, we may be obligated to seek hospitalization or contact law enforcement depending on context, severity, and form of disclosure. It must be noted that this topic may be discussed with providers, but if the provider feels there is adequate risk beyond therapeutic discussion of topic; or cannot guarantee without doubt the safety of you or others this limit may break the agreement, and all confidentiality may become null and void.

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Photo Consent and Release Form

I consent to photograph(s) to be taken of me by Devaraj behavioral Healthcare or a representative. I understand the images will be a part of my medical record and may be used for identifying me as a patient. 

By consenting to photographic images, I understand I will not be compensated by any party. Although photographic images will be used without identifying information such as name, I understand it is possible someone may recognize me. 

I further acknowledge that my participation is voluntary and agree that the use of any photographic image confers no rights of ownership or royalties whatsoever. 

I authorize the use of photographs *
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Consent for Treatment and Billing

Please review policy and sign at the end of the section:

The undersigned patient or responsible party (parent, legal guardian or conservator) consents to, and
authorizes services by Devaraj Behavioral Healthcare. These services may include but are not limited to:

- Psychotherapy
- Medication Services
- Recovery Coaching
- Supportive Counseling
- Case Management
- Group Counseling
- Lab / Toxicology Tests
- Diagnostic Procedures
- Mental Health Assessments
- Psychiatric Assessments
- Appropriate Alternative Therapy

The undersigned understands that the primary method of payment for services provided by Devaraj Behavioral Healthcare will be billed to presented insurance if applicable. This includes both private insurances, state Medicaid/Medicare. In the event these services are not covered by insurance the cost of said service would be sole responsibility· of the undersigned. In the event of rejected or uncovered services the undersigned will be notified by office staff before proceeding with treatment or resuming services.

The undersigned understands that he/she has the right to:

1. Receive a copy of this agreement
2. Request a list of services rendered
3. Withdraw consent from this agreement at any time (must be in writing).

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Telehealth / Telemedicine / Teletherapy Policy and Agreement

This Informed Consent for Telehealth contains important information focusing on providing healthcare / mental health services using the phone or the Internet.

Benefits and Risks of Telehealth
Telehealth refers to providing medical or mental health services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telehealth is that the patient and clinician can engage in services without being in the same physical location. This can be helpful particularly during the Coronavirus (COVID-19) pandemic in ensuring continuity of care as the patient and clinician likely are in different locations or are otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person treatment and telehealth, as well as some risks. For example:

- Risks to confidentiality. As telehealth sessions take place outside of Devaraj Behavioral Healthcare’s office, there is potential for other people to overhear sessions if you are not in a private place during the session. On our end, we will take reasonable steps to ensure your privacy. It is important; however, for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in a session only while in a room or area where other people are not present and cannot overhear the conversation.

- Issues related to technology. There are many ways that technology issues might impact telehealth. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.

- Crisis management and intervention. Normally, we will not engage in telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. We may not have an option of in-person services presently, but in a crisis situation, you may require a higher level of care. Before engaging in telehealth, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telehealth work.

Fees
The same fee rates will apply for telehealth as apply for in-person therapy. Some insurers are waiving co-pays during this time. It is important that you contact your insurer to determine if there are applicable co-pays or fees which you are responsible for. Insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic therapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in telehealth sessions in order to determine whether these sessions will be covered.


Informed Consent
This agreement is intended as a supplement to the general informed consent agreed to at the outset of treatment and does not amend any of the terms of that agreement.

Your signature or E-sginature below indicates agreement with its conditions and indicates you are willfully and within capacity to sign agreeing to its binding terms.

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