Adults: All Forms
SS77
Adult Background
Intake Form
Coordination of Benefits
Health Insurance Claim
Good Faith Estimate Notice
Informed Consent Notice
Telehealth Informed Consent Notice
HIPPA Notice
Adolescents (13-18): All Forms
Adult Background
Intake Form
Coordination of Benefits
Health Insurance Claim
Good Faith Estimate Notice
Informed Consent Notice
Telehealth Informed Consent Notice
HIPPA Notice
Adolescent History (Adolescent should fill out)
Child Treatment Consent
Child Problem Questionnaire (Adolescent should fill out)
ADHD Questionnaire
Family Questionnaire
Intake Form
Coordination of Benefits
Health Insurance Claim
Good Faith Estimate Notice
Informed Consent Notice
Telehealth Informed Consent Notice
HIPPA Notice
UBH/UHC Clients: All Forms
Additional Forms:
Child Treatment Consent
Child Problem Questionnaire (Adolescent should fill out)
ADHD Questionnaire
Family Questionnaire
Intake Form
Coordination of Benefits
Health Insurance Claim
Good Faith Estimate Notice
Informed Consent Notice
Telehealth Informed Consent Notice
HIPPA Notice
Release of Information Form (not needed initially)
Staff Only Forms:
Children (8-12): All Forms
Child Treatment Consent
Child Problem Questionnaire
ADHD Questionnaire
Family Questionnaire
Intake Form
Coordination of Benefits
Health Insurance Claim
Good Faith Estimate Notice
Informed Consent Notice
Telehealth Informed Consent Notice
HIPPA Notice
Children (0-7): All Forms
Child Problem Questionnaire
ADHD Questionnaire
Family Questionnaire
Intake Form
Coordination of Benefits
Health Insurance Claim
Good Faith Estimate Notice
Informed Consent Notice
Telehealth Informed Consent Notice
HIPPA Notice