Here are some commonly used forms that you may need to fill out. To simplify things, you can print and fill these forms out and bring them to your first appointment. It is easier to print an entire category of forms if that is what you need. Otherwise, just open and print the individual forms. If you are a UBH/UHC client, you'll also need to fill out the appropriate ALERT form below. Blank pages are used to separate forms when you print an entire category in case you are printing double-sided.
NOTE: ALL INTAKE PAPERWORK MUST BE COMPLETED AND BROUGHT WITH YOU BEFORE YOU WILL BE SEEN BY YOUR THERAPIST.
Adults:
All Forms
MBC Brochure (Read & Keep)
Client Information & Treatment Agreement
Client Identification
PHI Release for Billing
PHI Release for Physicians
Coordination of Benefits
Policies & Practices to Protect your Privacy
Email and Text Consent
Consent to Telehealth Visits
Adult History
Client Information & Treatment Agreement
Client Identification
PHI Release for Billing
PHI Release for Physicians
Coordination of Benefits
Policies & Practices to Protect your Privacy
Email and Text Consent
Consent to Telehealth Visits
Adult History
UBH/UBC Clients:
Children & Adolescents:
All Forms
MBC Brochure (Read & Keep)
Client Information & Treatment Agreement
Client Identification
PHI Release for Billing
PHI Release for Physicians
Coordination of Benefits
Policies & Practices to Protect your Privacy
Email and Text Consent
Consent to Telehealth Visits
Child Treatment Consent
Child Background (parents complete)
Child History (adolescents complete this)
Client Information & Treatment Agreement
Client Identification
PHI Release for Billing
PHI Release for Physicians
Coordination of Benefits
Policies & Practices to Protect your Privacy
Email and Text Consent
Consent to Telehealth Visits
Child Treatment Consent
Child Background (parents complete)
Child History (adolescents complete this)