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Patient Checklist & Policies

First-Time Visits

When you come to our office for the first time as a new patient, we’ll ask you to complete some initial forms, including an Authorization and a Consent for Treatment form, which will be sent to you electronically using our digital patient check-in platform.

All required registration and practice forms have to be completed prior to being seen.

If we do not have your completed forms on file prior to your visits we may ask you to reschedule your appointment.

We ask that you give special consideration to the Informed Consent form, which contains important information regarding your privacy, the psychological service offered, and insurance and billing information. We expect it will take 30 minutes to complete them.

Should you have additional questions about our procedures, matters of confidentiality, or insurance and billing, please ask us to clarify.

Email Us With Any Questions

Office Policies

Financial Policy — This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.

Notice of Privacy Practices — Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.

Health Insurance Portability and Accountability Act of 1996 (HIPAA) – This is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. The US Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to implement the requirements of HIPAA. The HIPAA Security Rule protects a subset of information covered by the Privacy Rule.

Before Your Visit…

To expedite your first appointment, here’s a helpful checklist of thing to do before your visit.

Complete patient registrations forms via OmniMD

Upload your insurance card

Upload your photo ID

Add the information for your copay

Mandatory Forms - All Clients

Notice of Privacy Practices

NOTICE OF 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 READ IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a Federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. HIPAA gives you, the patient, the right to understand and control how your personal health information (PHI) is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we prepared this explanation of how we are to maintain the privacy of your health information and how we may disclose your personal information.

We may use and disclose your medical records only for the following purposes: treatment, payment, and healthcare operation.
Provide clinical care and treatment for you at Orchard Mental Health Group
We can use and share your health information with clinicians at Orchard Mental Health Group , and other professionals who are involved in your treatment, for the purpose of providing you with the highest quality care.
Maintain organizational functioning
We can use and share your health information to maintain organizational functioning of Orchard Mental Health Group, improve your care, and contact you when necessary.
Bill you and your insurance provider for services
We can use and share your health information to bill and receive payment from your health insurance provider or other entities.
Assist with public health and safety issues
Preventing disease or helping with product recalls
Reporting adverse reactions to medications
Child abuse reporting: If there is a reason to suspect that a child (anyone under the age of 18) is or was abused or neglected, Maryland law requires reporting the matter immediately and providing relevant information to the Department of Social Services in the county/location where the abuse occurred. Emergency services may be contacted if the child is believed to be in immediate danger. Adult abuse reporting: If there is reason to suspect an elderly or incapacitated adult is abused, neglected or exploited, Maryland law requires reporting the matter and providing relevant information to the Department of Welfare or Social Services where the person currently resides. Emergency services may be contacted if the person is believed to be in immediate danger.
Preventing or reducing a serious threat to anyone’s health or safety: Under Maryland law, if you communicate to your clinician a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person or yourself, and they believe you have the intent and ability to carry out that threat immediately or imminently, they are legally required to take steps to protect you and third parties. These precautions may include (1) warning the potential victim(s), or the parent or legal guardian of the potential victim(s), if under the age of 18, (2) notifying law enforcement and/or other emergency services, or (3) seeking your hospitalization.
Comply with the law
We will share your health information as required by state or federal laws, including with the Department of Health and Human Services in order to show Orchard Mental Health Group’ compliance with federal privacy laws.
Address worker’s compensation, law enforcement, and other government requests This may include, but is not limited to, law enforcement purposes, health oversight agencies for activities authorized by law, and special government functions (i.e. military, national security, and presidential protective services).
Respond to lawsuits and legal actions o We will share health information about you in response to a court or administrative order, or in response to a subpoena. We will do our best to discuss with you any orders received before we carry out such orders.

We may contact you, by phone or in writing, to provide appointment reminders or information about treatment alternatives or other health-related benefits and services, in addition to other fundraising communications, that may be of interest to you. You do have the right to "opt out" with respect to receiving fundraising communications from us.

The following use and disclosures of PHI will only be made pursuant to us receiving a written authorization from you:

Most uses and disclosure of psychotherapy notes (these am not part of your medical record under HIPAA);
Uses and disclosure of your PHI for marketing purposes, including subsidized treatment and health care operations;
Disclosures that constitute a sale of PHI under HIPAA; and
Other uses and disclosures not described in this notice.

You may revoke such authorization in writing, and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your prior authorization.

You may have the following rights with respect to your PHI.

The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures of family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to honor a request restriction except in limited circumstances which we shall explain if you ask. If we do agree to the restriction, we must abide by it unless you agree in writing to remove it.
The right to inspect, copy and amend your PHI.
The right to receive an accounting of disclosures of your PHI.
The right to obtain a paper copy of this notice from us upon request.
The right to be advised if your unprotected PHI is intentionally or unintentionally disclosed.

We are required by law to maintain the privacy of your Protected Health Information and to provide you the notice of our legal duties and our privacy practice with respect to PHI.

By signing below, I affirm that I have read this document and understand it.

Client's First Name(Required)

Client's Last Name(Required)

Client's Date of Birth(Required)

This form is signed by(Required)

Signed By(Required)

First Last

Relationship to Client(Required)

Today's Date(Required)

Email(Required)

This field is required for online form submission.

New Patient Intake

Step 1 of 9

NEW PATIENT INTAKE

A. Demographics

Legal First Name(Required)

Legal Last Name(Required)

Preferred Name/Nickname (if different)

Date of Birth(Required)

Current Age(Required)

Legal Sex(Required)

Preferred Gender(Required)

Preferred Pronouns

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone Number(Required)

Email(Required)

This field is required for online form submission.

Highest Level Of Education Achieved

If "Other," please specify

Occupation

Marital Status

Religious Denomination/Affiliation, if applicable

Religious Involvement

Ethnicity/National Origin

Other Important Identifier(s)

B. Referral

How did you hear about Orchard Mental Health Group?(Required)

Who referred you?

C. Medical Care

Do you have a primary care physician (PCP?)(Required)

From whom or where do you receive medical care?

Phone Number

May we contact your medical doctor so that he or she can be fully informed and we can coordinate treatment?

Health Insurance Information

We will need to make a copy of your card(s).

Do you currently have medical insurance?(Required)

Front of Insurance Card

Max. file size: 128 MB.

If you don't upload this, we will need to make a copy at a later time.

Back of Insurance Card

Max. file size: 128 MB.

If you don't upload this, we will need to make a copy at a later time.

Primary Insurance Company(Required)

If "Other," please specify(Required)

Member ID(Required)

Group Number (if applicable)

Relationship to Subscriber(Required)

If "Other," please specify(Required)

Subscriber's Name (First Name & Last Name)(Required)

Subscriber's Date of Birth(Required)

Subscriber's Address (If different from own)

Street Address City State / Province / Region ZIP / Postal Code

Do you have a Secondary Insurance Company?(Required)

Front of Insurance Card

Max. file size: 128 MB.

If you don't upload this, we will need to make a copy at a later time.

Back of Insurance Card

Max. file size: 128 MB.

If you don't upload this, we will need to make a copy at a later time.

Secondary Insurance Company(Required)

If "Other," please specify(Required)

Member ID(Required)

Group Number (if applicable)

Relationship to Subscriber(Required)

If "Other," please specify(Required)

Subscriber's Name (First Name & Last Name)(Required)

Subscriber's Date of Birth(Required)

Subscriber's Address (If different from own)

Street Address City State / Province / Region ZIP / Postal Code

Financial Policy

FINANCIAL POLICY

Welcome to Orchard Mental Health Group (OMHG). We are pleased that you have chosen us as your healthcare provider. Our mission is to provide you with the highest level of professional medical care with the highest degree of patient satisfaction. To avoid any misunderstandings and ensure timely payment for services, it is important that you understand your financial responsibilities with respect to your health care.

CLIENT RESPONSIBILITIES & ACKNOWLEDGEMENTS

I, the client, understand the following:

1. Co-Pay: If my insurance plan has a copay requirement, I will be asked to pay your copay prior to being seen.

2. Deductible: I will be responsible for paying the deductible on my plan. OMHG will invoice me for any remaining balance once my insurance processes the claim.

3. Co-insurance: OMHG will ask me to pay a corresponding dollar amount to the percentage I am responsible for and OMHG will invoice me for any remaining balance once my insurance processes the claim.

4. Statements: Any balances remaining after payment from my carrier will be my responsibility. OMHG will charge the credit card on file for any balances on my account. Statements will be available to view on the Patient Portal. OMHG will not mail out paper statements.

5. Collections: Any delinquent account will be turned over to a collection agency after three (3) unpaid statements, unless a payment plan agreement is in place. Once an account has been turned over to collections, services will be suspended. Services may resume once the collection balance is paid in full.

6. Payment: Orchard Mental Health Group offers numerous ways for clients to pay for services. OMHG accepts Health Savings Cards, Credit Cards, and online payments. OMHG is not able to accept cash as a form of payment, due to reduced office staffing and increased Telehealth services.

7. Self-Pay: Self-Pay services are to be PAID IN FULL at the time of service. (See Self-Pay Agreement.)

8. Refunds: There must be no open claims on my account for OMHG to process a refund.

9. Insurance Verification: OMHG will attempt to verify my insurance eligibility prior to my visit. If OMHG is unable to confirm active insurance coverage, OMHG will contact me about ymy insurance eligibility. If I am unable to provide information about other active insurance coverage prior to my visit, I will be required to either 1) pay the self-pay rate at the time of my visit, or 2) reschedule my appointment.

10. Outstanding Balances: All outstanding balances are due on receipt. Any balances that occur on my account will be charged to the credit card on file. If I am unable to process your payment with the credit card on file, OMHG will request that I complete a new credit card authorization. If I come for another visit and have an outstanding balance, OMHG will request payment for both the new visit and my outstanding balance.

As mentioned in Section #4, statements can be viewed online via the patient portal. A copy of the explanations of benefits can be obtained from my insurance carrier that details the patient's responsibility. Accounts with unpaid balances for ninety (90) or more calendar days will be sent to an external collection agency for collection.

Unpaid balances can also lead to possible discharge from the practice.

11. Consent to Bill and Release Medical Information to Insurance Company: OMHG will submit claims to my insurance company. I authorize that payment of medical benefits be paid directly to OMHG for services provided.

I understand that OMHG may disclose all or any part of the medical record of the patient to my insurance company consistent with Federal HIPAA regulations. This authorization is given with full knowledge and understanding that such disclosure may contain information which may result in a valid denial of insurance benefits, or which otherwise may not serve my interests.

12. Late Arrivals, Cancellations, No-Shows & Dismissal:

a. Late Arrivals. If I am are more than seven (7) minutes late for a scheduled appointment, I may be asked to reschedule my ppointment and a fee will incur on my account. OMHG will try their best to accommodate late-comers as best as possible, but cannot compromise on the quality and timely care provided to OMHG's other clients.

b. Cancellations. If I am unable to keep a scheduled appointment, I must call, email, or cancel online, at least forty-eight (48) business hours in advance or OMHG will consider me a “no-show,” and a fee will incur my account. The 48-hour notice period excludes Fridays after business hours, as well as weekends.

c. No-Shows. If I miss my appointment, I will be charged a fee on my account. This fee cannot be billed to insurance.

d. Fees. Cancellation/No-Show fees vary across services.

- New Therapy Appointments: $125.00
- Follow-Up Therapy Appointments: $125.00
- New Medication Management Appointments: $150.00
- Follow-Up Medication Management Appointments: $100.00
- Testing Appointments: $400.00

13. Dismissal from Practice. If permitted by state law, you may be discharged as a patient following three (3) no-shows in a one-year period (365 days).

Client's First Name(Required)

Client's Last Name(Required)

Client's Date of Birth(Required)

This form is signed by(Required)

Signed By(Required)

First Last

Relationship to Client(Required)

Today's Date(Required)

Email(Required)

This field is required for online form submission.

Credit Card Authorization Form

CREDIT CARD AUTHORIZATION FORM

Quince Orchard Psychotherapy, dba/ Orchard Mental Health Group requires you to provide your credit/debit card information on file with us so we can automatically charge any co-pays, co-insurance, deductible amounts, and professional service charges such as late cancellation or missed appointment charges.

We store financial information and other protected health information in an encrypted, HIPAA compliant site. Your card(s) is/are processed for copays, co-insurance, and deductible amounts at the time of service and/or after the claim has been filed to and processed by your insurance carrier, and the insurance portion of the claim has posted to your account, or if valid insurance information was not provided at the time of service.

ACKNOWLEDGEMENTS & AGREEMENT

I, the client, understand that...

Once the insurance paid their portion for my care, I will receive an explanation of benefits (EOB) from them. The insurance EOB will state any balance to be paid by me.
Orchard Mental Health Group may charge my credit card on file for the balance due when they receive a copy of the EOB.
This authorization relates to all balances not covered by my insurance company for services provided by Orchard Mental Health Group. This could be amounts resulting from balances related to co-payment, deductible, co-insurance, non-covered services, or denials for no coverage/eligibility but is not limited to these scenarios.
If balance accrues and no payment is received, OMHG reserves the right to seek payment by any means, including using the credit/debit information OMHG has on file or retaining a collection agency. OMHG may be willing to work out a payment plan that includes a reasonable period for resolving the balance.
If my balance remains unpaid, OMHG reserves the right to suspend services until the balance is paid in part or in full.

Professional Service Fees
No-Show Fees & Late (<48 business hrs) Cancellation Fees	Medication Management Appointments	Initial Appointment: $150.00 Follow-Up Appointment: $100.00
	Therapy/Counseling Appointments	$125.00
	Testing/Evaluation Appointments	$400.00
Form Fees	Including, but not limited to Disability Forms, Miscellaneous Forms, etc.	$125.00/hr, prorated in 15-min increments
Other Professional Services Not Covered by Insurance	Including, but not limited to Professional Consultation (e.g. peer consultations, legal), Meeting Attendance (e.g. IEP meetings), Court Appearances	$150.00/hr

Client's First Name(Required)

Client's Last Name(Required)

Payer's Name - If different from client

First Last

Name as it Appears on the Credit Card

Same as the client's/payer's name

Name as it Appears on the Credit Card(Required)

Credit Card Billing Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Type of Card(Required)

Other Credit Card Type(Required)

Credit Card Number(Required)

Expiration date(Required)

CVV(Required)

Contact Email(Required)

This field is required for online form submission.

Contact Phone Number(Required)

Today's Date(Required)

Consent for Phone, Email & SMS Text Messaging

Consent for Phone, Email, and SMS Text Messaging

CONSENT FOR PHONE, EMAIL & SMS TEXT MESSAGING

I authorize my clinician and other staff at Orchard Mental Health Group to communicate with me via the following communication methods:(Required)

Telephone

Standard SMS Text Messaging

Cellphone Number - For Calls & SMS Messaging(Required)

I hereby consent to have my clinician and other staff at Orchard Mental Health Group communicate with me outside of the protected patient portal by email, telephone, or standard SMS text messaging, as specifically indicated above, regarding various aspects of my medical care. This may include, but is not limited to, scheduling, appointment, billing, mental health treatment, and other private, protected, and confidential health information.

I understand that Orchard Mental Health will make every effort to limit the amount of protected health information shared outside of the patient portal, and to ensure my privacy and confidentiality as best as possible; however, I understand that email, telephone and standard SMS text messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email, telephone and standard SMS text messaging regarding my medical care might be intercepted and read by a third party.

Client's First Name(Required)

Client's Last Name(Required)

Client's Date of Birth(Required)

This form is signed by(Required)

Signed By(Required)

First Last

Relationship to Client(Required)

Today's Date(Required)

Email(Required)

This field is required for online form submission.

Parental Consent Form for Minors Under 15

Parental Consent for Treatment of Minors Under 15

PARENTAL CONSENT FOR TREATMENT FOR MINORS UNDER 15

At Orchard Mental Health Group, we understand that families come in all different shapes and sizes. In order to provide your family with the best care, we must verify that we have the correct consent to treatment. We will require a copy of your photo ID along with the submission of this form.

The state of Maryland permits minors to consent to their own mental health treatment at the age of 16.
Any person under age 16 cannot be prescribed medicine without all legal guardians consenting to treatment.

THE FOLLOWING STIPULATIONS APPLY:

Biological Parents are Married: Only one parent’s signature is required.
Separated/ Divorced- One Parent Has Sole Legal and/or Medical Decision-Making Rights: If one parent has sole legal and/or medical decision-making rights for the patient, then only that parent’s signature is required along with a copy of the custody agreement before the patient can receive treatment.
Separated/ Divorced- Both Parents Have Joint Legal and/or Medical Decision-Making Rights: If parents are separated or divorced and have joint legal and/or medical decision-making rights for the patient, then BOTH parents’ signatures are required along with a copy of the custody agreement before the patient can receive treatment.
Legal Guardian/ Non-Biological Parent: Only the legal guardian’s signature is required for treatment. Please send any associated documentation to our office prior to the patient’s intake appointment.

Please select the applicable statement.(Required)

*You have indicated that the patient's biological parents are separated/divorced. Please select the applicable statement.(Required)

Custody Agreement

Max. file size: 128 MB.

You may also email a copy of your custody agreement to appointments@orchardmentalhealth.com, or fax it: 240-917-8735.

Custody Agreement

Max. file size: 128 MB.

You may also email a copy of your custody agreement to appointments@orchardmentalhealth.com, or fax it: 240-917-8735.

Other Parent's Email

If you would like us to send them a copy of this Parental Consent Form, please provide their email.

Other Parent's Name

To expedite the process, you may also direct them to fill out this form online.

Verification of Guardianship

Drop files here or

Max. file size: 128 MB.

You may upload multiple files for us to verify the information provided. You may also email them to appointments@orchardmentalhealth.com, or fax them: 240-917-8735.

Photo ID Upload

Max. file size: 128 MB.

You may also email a copy of photo ID to appointments@orchardmentalhealth.com, or fax it: 240-917-8735.

Your First Name(Required)

Your Last Name(Required)

Patient's Name(Required)

First Last

Relationship To Patient(Required)

Patient's Date of Birth(Required)

Today's Date(Required)

Email(Required)

This field is required for online form submission.

Thank you for your interest in our services.

We apologize for the inconvenience. However, because you have indicated that you do not have legal and/or medical decision-making rights, we unfortunately cannot proceed.

We will need the consent of the parent/guardian who does have such rights. Please refer them to this form, so that they may provide consent, as well as the applicable verification documents.

We cannot collect your information based on the responses provided. The signature field has been disabled.

For more information regarding forms, please contact us at appointments@orchardmentalhealth.com or call us during business hours: 240-750-6467.

Single-Session Therapy Clients Only

Single-Session (SST) Therapy Consent Form

Single-Session Therapy (SST) Consent

SINGLE-SESSION THERAPY (SST) CONSENT

In an effort to meet the demand for mental health support, Orchard Mental Health is offering Single Session Therapy (SST) to clients currently awaiting psychotherapy services. This is a form of brief therapy designed to provide some emotional relief and may be achieved through a single session of therapy. Please note, this is a pilot program to be evaluated and adjusted upon feedback.

You have been scheduled for a SST visit. This is not a guarantee of regular recurrent appointments with the same clinician after this single visit. You will remain (unless otherwise requested to be removed) on the waiting list in the same number order as the original new appointment request was initiated. This visit is insurance billable and subject to the same billing contracts as regular visits and will apply to your co-pay, co-insurance and/or deductible, if applicable. Or, if discussed during scheduling, the self-pay fee schedule will be collected at the time of service.

At the end of your 55-60 minute single session, you may request to schedule another SST, and for as many SST sessions you would like. This does not guarantee it will be with the same clinician or rhythm of day and time during the week. Attending a SST session does not guarantee a long-term counseling agreement and/or continuing therapeutic care.

We appreciate your feedback if a survey is received. All responses will be discussed and kept confidential, used for purposes of providing quality care for clients of Orchard Mental Health Group.

Client's First Name(Required)

Client's Last Name(Required)

Client's Date of Birth(Required)

This form is signed by(Required)

Signed By(Required)

First Last

Relationship to Client(Required)

Today's Date(Required)

Email(Required)

This field is required for online form submission.

Psychiatric Care - Evaluation & Medication Management Clients

Detailed Explanation of Consent for Psychiatric Evaluation & Treatment

DETAILED EXPLANATION OF CONSENT FOR
PSYCHIATRIC EVALUATION & TREATMENT

Detailed Explanation of Consent for Psychiatric Evaluation and Treatment Orchard Mental Health Group will only provide treatment to those to consent for this service.

The below is an expanded explanation of the Consent to Medical Care described in the form “Patient Care and Financial Responsibility Agreement”.

1. I, the client, voluntarily consent to participate (or allow my child to participate) in a mental health evaluation and subsequent treatment (as deemed medically appropriate and necessary) conducted by clinical staff at Orchard Mental Health Group. I understand that following the evaluation and/or treatment, information will be provided to me concerning each of the following areas:

a. The benefits of the proposed treatment;
b. Alternative treatment modes and services available;
c. The manner in which treatment will be administered;
d. Potential side effects from treatment and/or risks of side effects from medications (when applicable);
e. Probable consequences of not receiving treatment.

The evaluation and treatment will be conducted by a licensed Psychiatric Nurse Practitioner, Psychologists, Social Worker or Therapist. Treatment will be conducted within the boundaries of Maryland State Law.

2. Benefits of Psychiatric Evaluation and Treatment. Evaluation and treatment may be conducted by psychiatric and psychological interviews, psychological assessment or testing, psychotherapeutic interventions and medication management. It may be beneficial to me, as well as any referring professional, to understand the nature and cause of any difficulties affecting daily functioning, so that appropriate recommendations and treatments may be offered. Uses of the evaluation include, but are not limited to, diagnosis, evaluation of recovery or treatment, estimating prognosis, education and rehabilitation planning. Possible benefits of treatment include: Improved cognitive or academic/job performance, health status, quality of life, and awareness of strengths and limitations.

3. Charges. Fees are based on the length or type of evaluation or treatment, which are determined by the nature of the service deemed appropriate and/or necessary by clinical staff at Orchard Mental Health Group. I agree to be responsible for any charges not covered by insurance, including deductibles, co-insurance, copayments, late cancellation fees, no-show fees, and fees related to administrative services, such as the completion of disability evaluations, unemployment forms, and copying medical records.

The request for administrative services and the completion of clinical paperwork (copying medical records/documents, unemployment forms, disability evaluations, school forms, etc.) may take 7-10 business days to be completed depending on the nature of the request. A cost-based fee will be associated with these requests depending on the size and nature of the service.

4. Confidentiality, Harm and Inquiry. Information from my (or my child’s) evaluation and treatment is contained in a confidential medical record at Orchard Mental Health Group. I consent to disclosure and use of this information by Orchard Mental Health Group for the purpose of continuity of care. In accordance with Orchard Mental Health Group’ Privacy Practices and Patient Rights, and Maryland State Law, all patient information will be kept confidential with certain exceptions, including, without limitation, the following:

a. The patient presents an imminent danger to self or others.
b. There are reasonable concerns of abuse or neglect of a child or vulnerable adult.
c. A court order or subpoena is issued.

5. Right to Withdraw Consent. I have the right to withdraw my consent for evaluation and treatment (for myself or my child) at any time by providing a written request to Orchard Mental Health Group.

I voluntarily consent to participate in (or allow my child to participate in) evaluation and subsequent treatment as deemed medically appropriate and necessary by clinical staff at Orchard Mental Health Group.
I attest that I have the right to consent to evaluation and treatment (for myself or my child).
I will complete the associated Parental Consent for Treatment if I am consenting to the evaluation and treatment of a minor under the age of 16.
I have read this form in its entirety or had this form read/explained to me in its entirety.
I fully understand its contents, including the potential risks and associated benefits of participating in psychiatric evaluation and treatment.
I have been given the opportunity to ask questions and all of my questions have been answered to my satisfaction. I understand that I have the right to ask questions about the above information at any time.
I understand that I have the right to withdraw my consent for evaluation and treatment (for myself or my child) at any time and I understand how to do so.

By signing below, I affirm that I have read this agreement understand it.

Patient's First Name(Required)

Patient's Last Name(Required)

Patient's Date of Birth(Required)

This form is signed by(Required)

Signed By(Required)

First Last

Relationship to Patient(Required)

Today's Date(Required)

Email(Required)

This field is required for online form submission.

RX Refill - Controlled Substance Agreement

Prescription Refill Policy

PRESCRIPTION REFILL POLICY &
CONTROLLED SUBSTANCE PATIENT‐PROVIDER AGREEMENT

THE USE OF ANY CONTROLLED MEDICATION IS ONLY ONE PART OF TREATMENT FOR MY PSYCHIATRIC HEALTH.

Sleep, anxiety and an inability to concentrate are often treated with helpful medications that unfortunately are misused by some. When misused there are possible dangers of accidents, seizures, accidental overdoses and toxic effects (such as when these medications are used in large doses, mixed with alcohol, marijuana and other illegal drugs, and even medications prescribed for blood pressure, pain, and allergies). These medications, when misused can interfere with metabolism of other medications and cause potentially dangerous interactions. To prevent problems the following policies will be followed.

PROVIDER RESPONSIBILITIES

To make sure the medicine is helping and not hurting me.
To NOT continue medicines prescribed by others unless they are safe and are the best treatment for my problem.
To routinely check the state Prescription Monitoring Program, to see the medicines that I am getting from my OMHG provider and others.
To work with other specialists to make sure I am getting the best treatment for my problem.

PATIENT RESPONSIBILITIES - STANDARD PROCEDURES

I, the patient...

Will follow the treatment plan including keeping all appointments set up by my provider.
Am responsible for my medicines. I will not share, sell or trade my medicine.
Will keep my medicine in a safe place where no one else will be able to take them. They could be very dangerous to others, especially children.
Will not take anyone else's medicine.
Will not take extra medicine.
Will dispose of the medicine properly.
Understand that my medicine will probably not be replaced if it is lost, stolen, damaged or used-up sooner than prescribed.
Will not use any street or illegal drugs. I will not use any medications that have not been prescribed for me.
Will not drink alcohol while taking this medicine unless my provider says it is safe to do so.
Agree to give a urine sample for drug tests on the day it is requested whenever I am asked.
Will treat all people working in the practice with respect.

PATIENT RESPONSIBILITIES - PRESCRIPTIONS FROM OTHER PROVIDERS

If I, the patient, obtain pain medicine, sleep or anxiety medicine or a stimulant medicine from someone outside of primary care such as a dentist, psychiatrist or emergency room provider, I...

Am required to tell my provider the next time I am scheduled for a visit.
Will either bring this medication if scheduled onsite or show the original bottle during a virtual visit, even if the bottle is empty.

PATIENT ACKNOWLEDGEMENT - REFILLS

For GENERAL REFILLS, I, the patient, understand that...

Refills will require 72-hour notice and will be available during regular office hours from Monday to Friday from 9am-4pm Eastern Time.
It is important to keep my scheduled appointment to ensure that you receive timely refills.
Repeated no shows or cancellations will result in a denial of refills.
No refills for medications after-hours, nights, holidays or weekends.
If I fail to be seen prior to running out of medications, there will be a $25 charge to process my refills. At that time, you will be given enough medication to last you until your next appointment, usually within 2 weeks.

I, the patient, understand that some medications require PRIOR AUTHORIZATION, and...

Depending on my insurance, this process may involve several steps by both your pharmacy and your provider and could take several days or weeks.
The providers and pharmacies are familiar with this process and will handle the prior authorization as quickly as possible.
Neither the pharmacy nor the provider can guarantee that my insurance company will approve the medication.
I must check with my pharmacy or my insurance company for updates.

For REFILLS OF CONTROLLED SUBSTANCES, I, the patient, understand that...

I must be seen a minimum of every 3 months in order to be prescribed controlled medications.
Any requests for controlled medications following a canceled or no show appointment will be denied.
Emergency refills may only be made for up to 7 days along with a scheduled follow-up appointment within those 7 days.
No prescriptions for opiate-like pain medications will be prescribed. A patient should contact their primary care physician or a pain center for such medications.

DISCLAIMERS - I HAVE BEEN TOLD ABOUT THE POSSIBLE RISKS AND BENEFITS OF CONTROLLED SUBSTANCES.

I, the patient, understand that...

The medicine may help my problem, but may cause other problems like addiction, overdose and death.
When I start this medicine, when my dose is increased or if I drink alcohol or use street drugs, I may not be able to think clearly. I could become sleepy and have an accident.
I may get addicted to this medicine.

By signing below, I affirm that I have talked about this agreement with my provider and I understand it. I have had an opportunity to ask questions about the potential benefits and risks of the medicine prescribed.

Patient's First Name(Required)

Patient's Last Name(Required)

Patient's Date of Birth(Required)

This form is signed by(Required)

Signed By(Required)

First Last

Relationship to Patient(Required)

Today's Date(Required)

Email(Required)

This field is required for online form submission.

Miscellaneous Forms - All Clients, As Needed

Self-Pay Agreement Form

Self-Pay Agreement

SELF-PAY AGREEMENT

This self-pay agreement is intended to provide Orchard Mental Health Group's clients with an understanding of their financial responsibilities, should they elect to self-pay for our services.

Self-Pay Rates:

Clinician/Provider	New Intake	Follow-Up
Therapist	$200.00 (60 mins)	$160.00 (60 mins)
Psychologist	$250.00 (60 mins)	$180.00 (60 mins)
Nurse Practitioner	$300.00 (60 mins)	$150.00 (60 mins)

Evaluations for Adults Only
Remote ADHD Screen	$1,600.00
Presurgical Screen	$1,200.00

Evaluations for Children/Adolescents/Adults
Differential Diagnosis with No Cognitive	$3,250.00
Differential Diagnosis with Cognitive	$3,750.00
Autism Add On	$750.00
Academic Add On	$550.00

Failure to pay the charges outlined above may result in being discharged from services at Orchard Mental Health Group, or a suspension of services until all balances are paid in full.

I understand that by signing below, this authorization applies to all services provided to me, my dependents, or any other individuals for whom I have assumed responsibility. This authorization remains in effect from the date indicated below until it is formally revoked in writing.

Client's First Name(Required)

Client's Last Name(Required)

Client's Date of Birth(Required)

This form is signed by(Required)

Signed By(Required)

First Last

Relationship to Client(Required)

Today's Date(Required)

Email(Required)

This field is required for online form submission.

Informed Consent for Telehealth Services

INFORMED CONSENT FOR TELEHEALTH SERVICES

Telehealth means the remote delivering of health care services via technology assisted media

This includes a wide array of clinical services and various forms of technology. The technology includes but is not limited to video, internet, a smartphone, tablet, PC desktop system or other electronic means. The delivery method must be secured by two-way encryption to be considered secure. Synchronous (at the same time) secure video conference is the preferred method of service delivery.

Telehealth has the same purpose or intention as psychotherapy or psychological treatment sessions that are conducted in person. However, due to the nature of the technology used, I understand that teletherapy may be experienced somewhat differently than face-to-face treatment sessions.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

EXPECTED BENEFITS

Improved access to care by enabling a client to remain in his/her provider's office (or at a remote site) while the provider obtains test results and consults from practitioners at distant/other sites.
More efficient client evaluation and management.
Obtaining expertise of a distant specialist.

POSSIBLE RISKS

There are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by the providers and consultant(s);
Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment;
In very rare instances, security protocols could fail, causing a breach of privacy of personal health information;
In rare cases, a lack of access to complete health records may result in interactions or allergic reactions or other judgment errors;
Inability to Assess Nonverbal Cues: Some nonverbal cues may be limited or distorted in telecommunication, which could impact the therapeutic process.

CLIENT RIGHTS & ACKNOWLEDGEMENTS

I, the client...

Have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
Undestand that my provider also has the right to withdraw consent for the use of telehealth during the course of my care at any time; and
Understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
Understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required.
Understand that all rules and regulations that apply to clinical practice in the state of Maryland also apply to telehealth.

CLIENT RESPONSIBILITIES & ACKNOWLEDGEMENTS

I, the client...

Must be physically located in the state of Maryland during telehealth appointments (This is a legal requirement for all providers practicing in this state under a Maryland license.)
Will not record any telehealth sessions without the prior written consent of Orchard Mental Health Group. I understand that Orchard Mental Health Group or the practice’s providers will not record telehealth sessions without my consent;
Understand that there is a risk of being overheard by anyone near me if I am not in a private room while participating in telehealth.
Am responsible for (1) providing the necessary computer, telecommunications equipment, and internet access for my teletherapy sessions, and
Am also responsible for (2) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session. It is the responsibility of the treatment provider to do the same on their end.
Understand if I am unable to be in the State of Maryland or in a private space that my provider may terminate the session and I will be responsible for any late cancellation fees. The appointment will need to be rescheduled.
Understand that I may benefit from telehealth, but that results cannot be guaranteed or assured. I understand that there are potential risks and benefits associated with any form of mental health services, and that despite my efforts and the efforts of my provider, my condition may not improve, and in some cases may even get worse.
Accept that telehealth does not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273. TALK (8255) for free 24-hour hotline support.
Understand that clients who are actively at risk of harm to self or others are not suitable for teletherapy services. If this is the case or becomes the case in future, my provider will recommend more appropriate services.

Client's First Name(Required)

Client's Last Name(Required)

Client's Date of Birth(Required)

This form is signed by(Required)

Signed By(Required)

First Last

Relationship to Client(Required)

Today's Date(Required)

Email(Required)

This field is required for online form submission.

Supervisory Disclosure Form

Supervisory Disclosure

SUPERVISORY DISCLOSURE

The state of Maryland Board of Psychology rules governing licensed mental health professionals, as well as the American Psychological Association Ethical Codes, require that you be informed that the work of your therapist is being supervised by a licensed psychologist.

The primary supervisor has full responsibility for the supervised work of their supervisees. In order to ensure the highest standard of care, supervisors monitor and review the progress of your work with your therapist. The limits of confidentiality delineated in the informed consent for treatment apply to this supervised practice. The responsible supervisor for your therapist is listed below and is available for consultation upon request. If you have any questions about this supervisory relationship, we encourage you to talk to your therapist.

In compliance with the Maryland State Board of Psychology, we would like to inform you that the following therapists are under psychological work supervision with the following supervisors:

Supervisor	Clinician Under Supervision
Jessica Hasson, Ph.D. jessica.hasson@ochardmentalhealth.com	Tamika Parker
Jessica Hasson, Ph.D. jessica.hasson@ochardmentalhealth.com	Tamika Parker
Pamela Lubing, Psy.D. pamela.lubing@ochardmentalhealth.com	Justin Harker, M.S.
	Jacob A. Moore, M.S.
	Adrienne Petersen, M.A.
	Chioma Okeke, M.A.
Jessica Parrish, Ph.D. jessica.parrish@ochardmentalhealth.com	Linnea Payne, M.A
	Joseph Friedman, Psy.D.
	Timothy Kimball, M.A
	Ashley Rivera, M.A.
Michelle Pereira, Psy.D. michelle.pereira@ochardmentalhealth.com	Adrienne Reyes-Peña, Psy.D.
	Aiyanna Archer, Psy.D.
	Shadonna Harris, Psy.D.

Client's First Name(Required)

Client's Last Name(Required)

This form is signed by(Required)

Signed By(Required)

First Last

Relationship to Client(Required)

Email(Required)

This field is required for online form submission.

Today's Date(Required)

Know someone who could use our help?

We Gladly Take Referrals

Late Arrivals, Cancellations, No-Shows & Dismissal

Late Arrivals: If you are more than 7 minutes late for a scheduled appointment, you may be asked to reschedule your appointment and a fee will incur on your account. We will try our best to accommodate late-comers as best as possible, but cannot compromise on the quality and timely care provided to our other clients.

Cancellations: If you are unable to keep a scheduled appointment, you must call or email at least forty-eight (48) business hours in advance or we may consider you a “no-show” and a fee will incur on your account. Please note that the 48-hour notice period excludes Fridays after business hours, as well as weekends.*

No-Shows: If you miss your appointment without prior notice, you will be charged a fee on your account. Fees associated with missing appointments cannot be billed to insurance.

Here are the fees based on the type of appointment:

New Therapy Appointments: $125.00
Follow-Up Therapy Appointments: $125.00
New Medication Management Appointments: $150.00
Follow-Up Medication Management Appointments: $100.00
Testing Appointments: $400.00

Please call 240-750-6467 or email appointments@orchardmentalhealth.com if you need to cancel or reschedule an appointment.

*=For example, if a client leaves a message after 5pm Eastern time on a Friday, cancelling their appointment for the upcoming Monday, the client will incur a fee.

Cancel or Reschedule an Appointment

We accept many major insurances.

In crisis or need immediate help?
Call 988 or go to your nearest ER.

Contact Us

M-F, 9am-5pm Eastern Time
Phone: 240- 750-6467
Fax: 240-912-7835
contact@orchardmentalhealth.com

9707 Key West Avenue, Suite #100 Rockville, MD 20850

10 North Jefferson Street, Suite #202 Frederick, MD 21701

Privacy & Cookie Policies

Patient Checklist & Policies

First-Time Visits

Office Policies

Before Your Visit…

Mandatory Forms - All Clients

Notice of Privacy Practices

Notice of Privacy Practices

NOTICE OF 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 READ IT CAREFULLY.

The following use and disclosures of PHI will only be made pursuant to us receiving a written authorization from you:

You may have the following rights with respect to your PHI.

We are required by law to maintain the privacy of your Protected Health Information and to provide you the notice of our legal duties and our privacy practice with respect to PHI.

New Patient Intake

New Patient Intake

NEW PATIENT INTAKE

A. Demographics

B. Referral

C. Medical Care

Health Insurance Information

D. Emergency Contact

E. Chief Concern

F. Prior Treatment

G. Health

H. Unique Attributes

I. Relationships

J. Risk Taking

K. Other

Signature

Financial Policy

Financial Policy

FINANCIAL POLICY

CLIENT RESPONSIBILITIES & ACKNOWLEDGEMENTS

Credit Card Authorization Form

Credit Card Authorization Form

CREDIT CARD AUTHORIZATION FORM

ACKNOWLEDGEMENTS & AGREEMENT

Consent for Phone, Email & SMS Text Messaging

Consent for Phone, Email, and SMS Text Messaging

CONSENT FOR PHONE, EMAIL & SMS TEXT MESSAGING

Parental Consent Form for Minors Under 15

Parental Consent for Treatment of Minors Under 15

PARENTAL CONSENT FOR TREATMENT FOR MINORS UNDER 15

The state of Maryland permits minors to consent to their own mental health treatment at the age of 16. Any person under age 16 cannot be prescribed medicine without all legal guardians consenting to treatment.

THE FOLLOWING STIPULATIONS APPLY:

Thank you for your interest in our services.

Single-Session Therapy Clients Only

Single-Session (SST) Therapy Consent Form

Single-Session Therapy (SST) Consent

SINGLE-SESSION THERAPY (SST) CONSENT

Psychiatric Care - Evaluation & Medication Management Clients

Detailed Explanation of Consent for Psychiatric Evaluation & Treatment

Detailed Explanation of Consent for Psychiatric Evaluation & Treatment

DETAILED EXPLANATION OF CONSENT FORPSYCHIATRIC EVALUATION & TREATMENT

The below is an expanded explanation of the Consent to Medical Care described in the form “Patient Care and Financial Responsibility Agreement”.

RX Refill - Controlled Substance Agreement

Prescription Refill Policy

PRESCRIPTION REFILL POLICY &CONTROLLED SUBSTANCE PATIENT‐PROVIDER AGREEMENT

THE USE OF ANY CONTROLLED MEDICATION IS ONLY ONE PART OF TREATMENT FOR MY PSYCHIATRIC HEALTH.

PROVIDER RESPONSIBILITIES

PATIENT RESPONSIBILITIES - STANDARD PROCEDURES

PATIENT RESPONSIBILITIES - PRESCRIPTIONS FROM OTHER PROVIDERS

PATIENT ACKNOWLEDGEMENT - REFILLS

DISCLAIMERS - I HAVE BEEN TOLD ABOUT THE POSSIBLE RISKS AND BENEFITS OF CONTROLLED SUBSTANCES.

Miscellaneous Forms - All Clients, As Needed

Self-Pay Agreement Form

Self-Pay Agreement

SELF-PAY AGREEMENT

This self-pay agreement is intended to provide Orchard Mental Health Group's clients with an understanding of their financial responsibilities, should they elect to self-pay for our services.

Self-Pay Rates:

Informed Consent for Telehealth Services

Informed Consent for Telehealth Services

INFORMED CONSENT FOR TELEHEALTH SERVICES

Telehealth means the remote delivering of health care services via technology assisted media

EXPECTED BENEFITS

POSSIBLE RISKS

CLIENT RIGHTS & ACKNOWLEDGEMENTS

CLIENT RESPONSIBILITIES & ACKNOWLEDGEMENTS

Supervisory Disclosure Form

Supervisory Disclosure

SUPERVISORY DISCLOSURE

The state of Maryland permits minors to consent to their own mental health treatment at the age of 16.
Any person under age 16 cannot be prescribed medicine without all legal guardians consenting to treatment.

DETAILED EXPLANATION OF CONSENT FOR
PSYCHIATRIC EVALUATION & TREATMENT

PRESCRIPTION REFILL POLICY &
CONTROLLED SUBSTANCE PATIENT‐PROVIDER AGREEMENT

CONSENT TO RELEASE &
RECEIVE CONFIDENTIAL INFORMATION