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Client Checklist & Policies

Your one-stop place for Orchard Mental Health Group forms, consents, and helpful documents

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 AdvancedMD

Upload your insurance card

Upload your photo ID

Add the information for your copay

Please note: If any forms are required prior to your appointment, they will be available in your patient portal. If you need assistance accessing your portal or require login credentials, please contact us at contact@orchardmentalhealth.com or call our office for support.

Mandatory Forms:

All Clients, As Needed

Notice of Privacy Practices

HIPAA PRIVACY RULE OF PATIENT AUTHORIZATION AGREEMENT

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment;
A means of communication among the health professionals who may contribute to my health care;
A source of information for applying my diagnosis and surgical information to my bill;
A means by which a third-party payer can verify that services billed were actually provided;
A tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals.

I have been provided with a copy of the Notice of Privacy Practices if requested that provides a more complete description of information uses and disclosures.

I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this Practice’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

Privacy Rule of Patient Consent Agreement

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

I understand that:

I have the right to review this Practice’s Notice of Information practices prior to signing this consent;
This Practice reserves the right to change the notice and practices and that prior to implementation will mail a copy of any notice to the address I’ve provided, if requested;
I have the right to object to the use of my health information for directory purposes;
I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that this Practice is not required by law to agree to the restrictions requested;
I may revoke this consent in writing at any time, except to the extent that this Practice has already taken action in reliance thereon.

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)

Guarantor Name

if applicable

Today's Date(Required)

Email(Required)

This field is required for online form submission.

New Patient Intake

Step 1 of 9

X/Twitter

This field is for validation purposes and should be left unchanged.

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 2026

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-Pays: Patients with insurance plans that include a copay requirement are required to pay their copay before receiving services.

2.) Deductible: You are required to pay the deductible specified by your insurance policy. After your insurance provider has processed the claim, we will issue an invoice for any outstanding balance.

3.) Co-insurance: Co-insurance is the amount a client with insurance must pay for claims after exceeding their deductible. You will be responsible for paying the outstanding amount that you are responsible for after your insurance has processed your claim.

4.) Statements: Any balances remaining after payment from your insurance provider will be your responsibility to pay. OMHG will charge the credit card on file for any balances on your account. Statements will be available to view on the patient portal. OMHG does not mail out paper statements.

5.) Delinquent Accounts and Collections: Our collections process is as follows.

Account Delinquency: Accounts become delinquent when payment has not been received within thirty (30) calendar days of the statement date. Any delinquent account will be turned over to a third-party collection agency after three consecutive unpaid statements, approximately 90 days past due, unless a formal payment plan agreement has been executed and is being followed in good faith. All clinical services will be immediately suspended once an account enters collections status. This includes therapy sessions, medication management, testing services, and any scheduled appointments, which will be cancelled without further notice.
Collection Process: Once an account has been referred to collections, you will receive written notification of the transfer. The collection agency will contact you directly regarding payment arrangements. Collection accounts may be reported to credit bureaus, which could negatively impact your credit score and credit history. You will be responsible for all collection costs, including but not limited to collection agency fees, court costs, and reasonable attorney fees if legal action becomes necessary.

6.) Chargebacks and Reversals of Payments: In the event that a patient initiates a chargeback or reverses previously paid fees to OMHG through their banking institution or credit card provider, we reserve the right to reassess our working relationship and may need to suspend services and/or discharge a client from our practice.

7.) Payment: OMHG offers numerous ways that you can pay for services. We accept Health Savings Cards, Credit Cards, or online payments. We do not accept cash as a form of payment.

8.) Self-Pay: Self-Pay services are to be PAID IN FULL at the time of service. The costs are as follows:

Individual Services by Provider Type

Provider Type	New Intake	Follow-Up
Master Level Therapist	$200.00 (60 min)	$175.00 (60 min)
Psychologist	$250.00 (60 min)	$185.00 (60 min)
Nurse Practitioner	$375.00 (60 min)	$150.00 (20 min) $200.00 (40 min)

Couples/Family Therapy

Provider Type	New Intake	Follow-Up
Master Level Therapist	$200.00 (60 min)	$175.00 (60 min)
Psychologist	$250.00 (60 min)	$185.00 (60 min)

Group Therapy

$80.00 (60 minutes)

Walk-Ins and Rapid Care Services

Provider Type	New Intake	Follow-Up
Master Level Therapist	$325.00 (60 min)	$200.00 (60 min)
Psychologist	$350.00 (60 min)	$225.00 (60 min)
Nurse Practitioner	$375.00 (60 min)	$150.00 (20 min) $200.00 (40 min)

Testing and Evaluation Services

Standard clinical hourly rate for testing and evaluation service is $200.00.

Differential Diagnosis No Cognitive	$3,250.00
Differential Diagnosis w/ Cognitive	$3,750.00
Autism Add On	$750.00
Academic Add On	$550.00
ADHD - Remote Testing	$1,600.00
Presurgical Evaluation	$1,200.00
ADHD Targeted Evaluation*	$200.00 per hour
Gender Affirming Surgery Letter	$130.00

*Master level clinicians providing clinical evaluation without full testing battery. Not be used for accommodation requests. Best for informing treatment recommendations.

These Self Pay rates show the cost of items and services that are reasonably expected for healthcare needs. You could be charged more if additional services are needed or special circumstances occur. If this happens, federal law allows you to dispute the bill with the U.S. Department of Health and Human Services (HHS). If you choose to dispute the balance, you must start the dispute process within 120 calendar days of the original bill. If you have any questions about Self Pay services, please contact us at 240-750-6467.

9.) Refunds: Refunds must be requested via phone or email. In order to process your refund, you must not have any outstanding balances on your account, and not have future appointments that would incur a balance. Once the refund is approved, payments made within 90 days will be refunded directly to the card used to pay. For any payments older than 90 days, a physical check will be mailed to you.

10.) Insurance Verification: We will attempt to verify your insurance eligibility prior to your visit. If we are unable to confirm active insurance coverage, we will contact you about your insurance eligibility. If you are unable to provide information about other active insurance coverage prior to the visit, you will be required to either pay the self-pay rate at the time of your visit or reschedule your appointment.

11.) Changes and Updates to Insurance: I understand that it is my responsibility to update OMHG of any changes or updates to my insurance eligibility and coverage immediately.

12.) Outstanding Balances: All outstanding balances are due on receipt. Any balances that occur on my account will be charged to the mandatory credit card on file. Accounts with unpaid balances for ninety (90) or more calendar days will be sent to an external collection agency. If you are unable to pay your balance in full, a payment plan may be requested.

Payment Plan Eligibility: Payment plan agreements must be requested in writing and approved by OMHG's billing department prior to the account reaching collection status. Payment plans require a minimum monthly payment of $50.00 or 10% of the outstanding balance, whichever is greater, and must provide for full payment within twelve (12) months of the agreement date.

13.) Consent to Bill and Release Medical Information to Insurance Company: I understand that 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.

14.) Fees Not Billed to Insurance

Late Cancellations and No-Shows. If I am unable to keep a scheduled appointment, I must cancel at least forty-eight (48) hours in advance for therapy and medication management, and four business days in advance for testing administration or I will be charged a fee on my account. The business-hours notice period excludes Fridays after business hours, as well as weekends.

If I am not in the state in which my provider holds an active practice license during my scheduled telehealth appointment, I understand that my provider is unable to provide service and a late cancellation fee may apply.

If I am more than seven (7) minutes late for a scheduled appointment, I may be asked to reschedule my appointment and be charged a late cancellation fee.

Late Cancellation and No-Show Fees

Medication Management	Initial Appointment $150.00 Follow-Up Appt $100.00
Therapy/Counseling	$125.00
Testing/Evaluation	Intake $125.00 Testing $400.00

Professional Service Fees

Form Fees Disability Forms, Miscellaneous Forms, etc.	$140.00/hour prorated in 15-min increments
Other Professional Services Including, but not limited to Professional Consultation, peer consultations, Meeting Attendance, IEP meetings	$200.00/hour
Court Appearances and Related Services	$450.00/hour

Court-related services are not a standard part of clinical treatment and will be billed separately. These services may include, but are not limited to professional consultation, review of documents and preparation time, court attendance, testimony, depositions, waiting time, and travel to/from court.

All court-related services are billed at the standard court appearances and related services rate and are payable in advance unless otherwise arranged.

15.) Dismissal from Practice. Failure or refusal to pay for services after a reasonable time may result in termination of services.

16.) Credit Card on File: OMHG requires you to provide your credit/debit card information so we can automatically charge any co-pays, co-insurance, deductible amounts, and professional service charges such as late cancellation or missed appointment fees.

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.
OMHG may charge my credit card on file for the balance due when they receive a copy of the EOB.
This policy relates to all balances not covered by my insurance company for services provided by OMHG.
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.
If my balance remains unpaid, OMHG reserves the right to suspend services until the balance is paid in part or in full.
I have the right to dispute any charges sent to collections within thirty (30) days of receiving collection notice. I also have the right to request debt validation and to be treated fairly under the Fair Debt Collection Practices Act.

By signing this agreement, I acknowledge and consent to these payment policies.

I understand that I will be responsible for all charges and fees related to the services provided to me by OMHG.
I authorize OMHG to securely capture and charge my card on file for any balance owed on my account.
I understand the Self Pay rates, should I elect to pay Self Pay or if my insurance is not active for my visit.
I understand the above no-show and late cancellation fees apply if I fail to provide required notice prior to my scheduled appointment. I understand these fees cannot be billed to insurance.
I understand the above professional service fees apply should these services be rendered. I understand these fees cannot be billed to insurance.

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)

Client's First Name(Required)

Client's Last Name(Required)

Payer's Name

Same as client's name

Payer's Name

First Last

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 (OMHG) 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 OMHG 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. When signing up for the patient portal, you authorize receipt of automatic appointment reminders and links to join telehealth appointments sent via text and email (this may be disabled by the portal user or by calling 240-750-6467).

I understand that OMHG 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

Parental Consent for Treatment of Minors

PARENTAL CONSENT FOR TREATMENT FOR MINORS

At Orchard Mental Health Group (OMHG), 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.

In Maryland, any person under age 16 cannot be prescribed medication without all legal guardians consenting to treatment.

Please Review the Following Consent Requirements

The patient's biological parents are married.
Only one parent must provide consent.
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 provide any associated documentation prior to the patient's intake appointment.

If I have indicated that the patient's parents are separated/divorced, with both parents having joint legal and/or medical decision-making rights, I understand that at least one parent is required to furnish a copy of the custody agreement before the patient can receive treatment.

If you would like OMHG to send the other party a copy of this Parental Consent Form, please provide their email address in the field below.

By selecting the appropriate custody status and signing this form, I certify that the information provided is accurate and that I have the legal authority to consent to treatment for the minor patient.

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.

***If you selected the option “Separated/ Divorced- Both Parents Have Joint Legal and/or Medical DecisionMaking Rights:” You must contact the office and request an additional minor consent form to be sent to the other parent/medical decision-maker. Any person under age 16 cannot be prescribed medicine without all legal guardians consenting to treatment. If this form is not signed by both parents at time of appointment, no medications will be prescribed. ***

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.

Consent for Psychiatric Evaluation & Treatment

Consent for Psychiatric Evaluation and Treatment

Consent for Psychiatric Evaluation and Treatment

Welcome to Orchard Mental Health Group (OMHG). Your consent is required before receiving any treatment at OMHG. Please read this information thoroughly to ensure you understand your rights, responsibilities, and the scope of care provided.

I am aware that my provider is required to review the policies on this form and is available to answer any questions. If treatment is for a minor, I affirm that I have the legal right to seek non-emergency mental health treatment for my child.

Client Rights and Responsibilities

You have the right to:

Be treated with dignity, respect, and without discrimination.
Receive care that is considerate of your cultural, spiritual, and personal values.
Participate actively in the development of your treatment plan.
Be informed of the potential benefits, risks, and alternatives of recommended treatments.
Refuse treatment or request a second opinion.
Ask questions at any time about your diagnosis, treatment plan, or medications.
Confidentiality of your records and communications, except as required or permitted by law.
Access your medical records within the timeframe established by Maryland law.
File a grievance or complaint without fear of retaliation.

You are responsible for:

Providing accurate and complete information about your health, history, medications, and other relevant factors.
Actively participating in your treatment plan.
Taking medications as prescribed and discussing concerns or side effects with your provider.
Treating staff and other clients with courtesy and respect.
Keeping scheduled appointments and providing timely notice for cancellations or rescheduling.
Understanding your insurance coverage and financial responsibility.
Informing your provider promptly if your condition changes or if you experience a crisis.

Benefits and Risks of Evaluation and Treatment

Psychiatric evaluation and treatment may include psychotherapy, medication management, testing, or a combination of services. Treatment may help reduce symptoms, improve mood and functioning, increase coping skills, and support personal growth. However, outcomes are not guaranteed, and treatment may involve risks such as medication side effects, difficult emotions, or temporary worsening of symptoms.

Telehealth Services

Telehealth may be available when appropriate. Clients must be physically located in a state where their provider is licensed during telehealth sessions. Telehealth requires a private location, reliable internet connection, webcam, and microphone.

Medication

If medication is prescribed, I agree to follow my prescribing practitioner’s directions and discuss any side effects, concerns, or medication changes with my provider.

Confidentiality

OMHG works to protect client confidentiality. However, exceptions may apply when disclosure is required by law or ethics, including abuse or neglect, risk of harm to self or others, court orders, regulatory obligations, complaints, litigation, operational needs, or clinical supervision.

Medical Records

I understand that I have the right to request a copy of my medical records or authorize release of records to a third party through a signed Release of Information. Records will be provided within 21 business days of receipt of a valid written request, in accordance with Maryland law.

Emergency Contact Procedures

In an emergency or mental health crisis, I understand that I should go directly to the emergency room, call 988, or call 911 for immediate assistance.

Right to Withdraw Consent

I understand that I may withdraw my consent for evaluation or treatment at any time by submitting a written request to OMHG.

Acknowledgement of Understanding

I have read or had explained to me this consent form in its entirety.
I understand the potential benefits, risks, and financial responsibilities.
I have had the opportunity to ask questions.
I understand my right to withdraw consent at any time.

By checking the consent box below, I acknowledge that I have read, understand, and voluntarily consent to participate, or allow my child to participate, in psychiatric evaluation and treatment services provided by 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.

MEDICATION MANAGMENT CLIENTS: RX Refill - Controlled Substance Agreement

Prescription Refill Policy

PRESCRIPTION REFILL POLICY &
CONTROLLED SUBSTANCE PATIENT‐PROVIDER AGREEMENT

Orchard Mental Health Group has adopted this Prescription/Refill Policy to ensure the safety and well-being of our patients, maintain compliance with regulatory standards, and provide efficient, consistent care.

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 - GENERAL PERSCRIPTION POLICIES

For REFILL REQUESTS, 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.
My appointment must be scheduled before any refill requests are completed.
If I do not have an appointment scheduled, I must first schedule one and then request the refill.
For unplanned refill requests, a fee of $25 will apply. Examples of unplanned refills include lost prescriptions, missed appointments due to no-shows or failure to schedule, or leaving a prescription behind during travel.
If the lost medication is a controlled substance, refills may require waiting until the next prescription is due.
Repeated no shows or cancellations will result in a denial of refills.
No refills for medications after-hours, nights, holidays or weekends.

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...

Controlled substances include medications such as stimulants and benzodiazepines. These are subject to strict state and federal regulations.
If you are prescribed a controlled substance, your nurse practitioner may require periodic urine drug screens to be completed at a local laboratory facility, such as Quest or LabCorp.
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, therefore I should contact my primary care physician or a pain center for such medications.
Documentation, such as a police report, may be required for lost or stolen controlled medications to comply with regulations.
Depending on my circumstances and legal requirements, in-person appointments may be required for refills of controlled substances.
If I am a college students or live in shared accommodations, a personal medicine safe is highly recommended to prevent loss or theft.

As far as PHARMACY COORDINATION, I, the patient, understand that...

If my prescription is out of stock at my primary pharmacy, my nurse practitioner will send it to a secondary pharmacy of my choice, HOWEVER,
It is my responsibility to locate a pharmacy with stock availability.
My nurse practitioner is not obligated to search for a pharmacy with the medication in stock.

For MEDICATION CHANGES, I, the patient, understand that...

Medication changes should generally be discussed during a scheduled appointment.
In emergencies or when immediate appointments are unavailable, my nurse practitioner may agree to adjust medications through secure message exchanges, BUT
This is at my nurse practitioner's discretion and subject to a $50 fee for changes made outside of appointments.

For EMERGENCY AND EXCEPTIONAL CIRCUMSTANCES, I, the patient, understand that...

Fees for unplanned refills or medication changes may be waived in exceptional situations, such as natural disasters, hospitalization, or other emergencies, and
That these cases will be evaluated individually.

PROPER MEDICATION DISPOSAL

Patients are encouraged to dispose of unused or expired medications properly to prevent misuse or environmental harm. Resources for safe disposal methods are available upon request.

ADDITIONAL INFORMATION

Any charges for unplanned refill requests or medication changes must be paid out-of-pocket.

Refill requests should be submitted through the patient portal or via email to contact@orchardmentalhelth.com. For urgent concerns, contact the office directly during business hours at 240-750-6467

To avoid lapses in medication, patients are advised to schedule follow-up appointments at least two weeks before their prescriptions run out.

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

I as the patient, am required to acknowledge and agree to these policies as part of their treatment agreement. This acknowledgment ensures my understanding of responsibilities and expectations related to prescriptions and refills.

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.

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:

Medication Management	Initial	$150.00
Medication Management	Follow-Up	$100.00
Therapy/Counseling	Initial	$125.00
Therapy/Counseling	Follow-Up	$125.00
Testing/Evaluation	Intake	$125.00
Testing/Evaluation	Evaluation	$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

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	Intake Appointment: $125.00 Evaluation Appointment: $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

Supervisor	Clinician Under Supervision
William Strahl, Psy.D william.strahl@ochardmentalhealth.com	Eleonora Sadikova, Psy.D.
William Strahl, Psy.D william.strahl@ochardmentalhealth.com	Amber Smith, Psy.D.
Pamela Lubing, Psy.D. pamela.lubing@ochardmentalhealth.com	Temple Price, M.A.
Pamela Lubing, Psy.D. pamela.lubing@ochardmentalhealth.com	Chioma Okeke, M.A.
Jessica Parrish, Ph.D. jessica.parrish@ochardmentalhealth.com	Hernan Cordano, M.A.
	Garra Appling, M.A.
	Selima Jumarali, Ph.D.
Michelle Pereira, Psy.D. michelle.pereira@ochardmentalhealth.com	Jessica De Leon, Psy.D.

Client Checklist & Policies

First-Time Visits

Office Policies

Before Your Visit…

Mandatory Forms:

All Clients, As Needed

Notice of Privacy Practices

Notice of Privacy Practices

HIPAA PRIVACY RULE OF PATIENT AUTHORIZATION AGREEMENT

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

Privacy Rule of Patient Consent Agreement

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

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 2026

FINANCIAL POLICY

Client Responsibilities & Acknowledgements

Individual Services by Provider Type

Couples/Family Therapy

Group Therapy

Walk-Ins and Rapid Care Services

Testing and Evaluation Services

Late Cancellation and No-Show Fees

Professional Service Fees

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

Parental Consent for Treatment of Minors

PARENTAL CONSENT FOR TREATMENT FOR MINORS

Please Review the Following Consent Requirements

Thank you for your interest in our services.

Consent for Psychiatric Evaluation & Treatment

Consent for Psychiatric Evaluation and Treatment

Consent for Psychiatric Evaluation and Treatment

Client Rights and Responsibilities

Benefits and Risks of Evaluation and Treatment

Telehealth Services

Medication

Confidentiality

Medical Records

Emergency Contact Procedures

Right to Withdraw Consent

Acknowledgement of Understanding

MEDICATION MANAGMENT CLIENTS: 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 - GENERAL PERSCRIPTION POLICIES

PROPER MEDICATION DISPOSAL

ADDITIONAL INFORMATION

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

Single-Session Therapy Clients Only

Single-Session (SST) Therapy Consent Form

Miscellaneous Forms:All Clients, As Needed

Credit Card Authorization Form

Credit Card Authorization Form

CREDIT CARD AUTHORIZATION FORM

ACKNOWLEDGEMENTS & AGREEMENT

Supervisory Disclosure Form

Supervisory Disclosure

PRESCRIPTION REFILL POLICY &
CONTROLLED SUBSTANCE PATIENT‐PROVIDER AGREEMENT

Miscellaneous Forms:
All Clients, As Needed

CONSENT TO RELEASE &
RECEIVE CONFIDENTIAL INFORMATION