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Client 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 AdvancedMD

Upload your insurance card

Upload your photo ID

Add the information for your copay

Mandatory Forms - All Clients, As Needed

Notice of Privacy Practices

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;
that 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

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: 256 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: 256 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: 256 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: 256 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: Orchard Mental Health Group

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)

Financial Policy: GBCC

Financial Policy 2026 (GBCC)

FINANCIAL POLICY

Welcome to GBCC Behavioral Health (GBCC). 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.

4.) Statements: Any balances remaining after payment from your insurance provider will be your responsibility to pay. GBCC will charge the credit card on file for any balances on your account. Statements will be available to view on the patient portal. GBCC 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 GBCC 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: GBCC 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(20min) 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(20min) 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.

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

Payment Plan Eligibility: Payment plan agreements must be requested in writing and approved by GBCC'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 GBCC will submit claims to my insurance company. I authorize that payment of medical benefits be paid directly to GBCC for services provided.

I understand that GBCC 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

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

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: GBCC 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.
GBCC 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 GBCC.
If balance accrues and no payment is received, GBCC reserves the right to seek payment by any means, including using the credit/debit information GBCC has on file or retaining a collection agency.
If my balance remains unpaid, GBCC 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 GBCC.
I authorize GBCC 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

2026 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.

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.

Patient First Name(Required)

Patient Last Name(Required)

Date of Birth(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 medicine 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. (See below) ***
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.

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 us to send the other party a copy of this Parental Consent Form, please provide their email.

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: 256 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: 256 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: 256 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: 256 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 and Treatment: Orchard Mental Health Group

2026 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. If at any time I should lose the right to seek care for my child, I will inform the treatment provider as soon as possible, prior to any further treatment occurring.

Client Rights and Responsibilities

As a client receiving psychiatric services at OMHG, you have important rights and responsibilities to help ensure safe, ethical, and effective care. Evaluations and treatments will be conducted by licensed clinical professionals, such as Psychiatric Nurse Practitioners, Psychologists, Social Workers, Therapists, or provisionally licensed providers under supervision, in accordance with applicable state law. Please review the following:

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, including decisions about medications and other interventions.
Be informed of the potential benefits, risks, and alternatives of recommended treatments.
Refuse treatment or request a second opinion, understanding that refusal may affect treatment outcomes.
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 (e.g., risk of harm to self/others, child/elder abuse, court order).
Access your medical records within the timeframe established by Maryland law (21 business days).
File a grievance or complaint about your care 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 and following agreed-upon recommendations.
Taking medications as prescribed and discussing any concerns or side effects with your provider before making changes.
Treating staff and other clients with courtesy and respect.
Keeping scheduled appointments and providing timely notice if you need to cancel or reschedule.
Understanding your insurance coverage and financial responsibility for services.
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, which may include psychotherapy, medication management, testing, or a combination, can be helpful for many individuals. However, as with any medical or mental health care, there are potential benefits as well as risks.

Potential Benefits

Reduction in symptoms such as anxiety, depression, or other distressing experiences.
Improved mood, functioning, and quality of life.
Increased ability to manage stress, relationships, and daily responsibilities.
Development of new coping skills and healthier patterns of thinking and behavior.
Enhanced self-awareness and personal growth.

Potential Risks

Psychiatric medications may cause side effects, which can range from mild (e.g., drowsiness, nausea) to more serious (e.g., changes in mood, metabolic effects, or rare but significant medical complications).
It may take time to find the most effective medication and dosage, and adjustments may be necessary.
Psychotherapy may bring up difficult emotions, memories, or increased distress before improvement occurs.
There is no guarantee of specific outcomes, and some individuals may not experience the results they hope for.
In rare cases, treatment may temporarily worsen symptoms, requiring close communication with your provider.

Termination or Discharge

While the purpose of services is to manage or alleviate symptoms of a concerning issue or condition, we can not guarantee improvement. If your provider determines that he/she/they are not effective in helping you achieve your goals, your provider is required to discuss this with you. In some situations it may be appropriate to terminate treatment and provide referrals to other clinical professionals.

You also have the right to terminate treatment at any time, however we highly recommend discussing this with your treating provider before making a decision. If you do choose to terminate, your provider may offer additional resources for you to continue treatment elsewhere. Should you wish to transfer care to another provider in the practice, you must initiate a transfer request form to be reviewed carefully by clinical management to ensure the transfer is appropriate.

OMHG also reserves the right to terminate treatment given certain circumstances. We will not tolerate violent acts, threats, or harassment towards your provider, their colleagues, or their family. Your provider reserves the right to terminate your treatment unilaterally and immediately in such situations.

Unless we have made other arrangements, should you not schedule an appointment for a period of 60 days and make no other arrangement with your provider, you agree that you will no longer be considered to be an active client, and therefore have terminated treatment.

If you "no show"/"late cancel" for two consecutive appointments, you will be discharged from treatment. Three "no show"/"late cancel" for appointments scheduled in a twelve month period (365 days) will also be discharged from treatment.

Patient Portal

All written communications to/from your provider must be completed through the patient portal. Please allow 48 business hours for a response. Your provider will limit patient portal communications with you to non-urgent issues.

You should schedule an appointment if the issue is too complex or sensitive to discuss via the patient portal. Patient portal is not appropriate for an urgent matter or an emergency situation.

Patient portal messages are checked on a regular basis; however there may be exceptions to this. You are responsible for following up with your provider or support staff if you have not received a response. All messages will be filed electronically in your record.

Prescription refill requests should be submitted when you have 1-2 weeks worth of medication remaining. Please allow 72 business hours for your request to be processed. The practice has no control over pharmacy stocking of medications or filling prescriptions.

Telehealth Services

It may be possible for psychiatric evaluation and treatment to occur via interactive videoconferencing in addition to, or in lieu of "in person" sessions. Telehealth means the remote delivering of healthcare services via technology assisted media. This includes a wide array of clinical services and various forms of technology.

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.

Mental health treatment via Telehealth is not appropriate for all individuals or all problems being treated. Your provider will make the decision regarding appropriateness for telehealth, and this may change at any time. Telehealth has the same purpose or intention as psychotherapy or psychological treatment sessions that are conducted in person.

Licensure regulations only allow a Telehealth session to be conducted in the state in which the provider is licensed (e.g. Maryland, Virginia) and the client is geographically located. That is, you must be physically located in the state in which your provider holds an active practice license during all Telehealth sessions.

Not all insurance companies reimburse for mental health treatment via Telehealth. Fees for sessions rendered via Telehealth are the same as in-person sessions (see financial policy).

You do not need to create an account or download an app to participate in Telehealth sessions. You do need:

Computer, tablet, or smart phone with an external or integrated webcam
An external or integrated microphone
An internet connection with sufficient speed to conduct audio-video sessions. An ethernet cable over Wifi when possible, as well as shutting down all background applications is recommended for the best connection.
A private location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.

Technology based and clinical risks of mental health treatment via Telehealth may include (but are not limited to):

The technology platform dropping due to poor internet connection
Delay in treatment due to connections or other technologies
In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by the provider
In very rare instances, security protocols could fail, causing a breach of privacy of personal health information
Privacy breach from your geographical location or the technology used which is outside of the provider's control
Discomfort with virtual versus in-person sessions
Difficulty interpreting non-verbal communication
Reduced access to immediate resources if risk of self-harm or harm to others becomes apparent

I will not record any telehealth sessions without the prior written consent of OMHG. I understand that OMHG or the practice's providers will not record telehealth sessions without my consent.

I understand that all rules and regulations that apply to clinical practice in the state of Maryland also apply to telehealth.

Use of Third-Party Tools and Platforms

As part of providing high-quality care, our practice may use secure third-party platforms and tools that support our clinical and administrative processes. These tools may assist with organizing information, supporting documentation, or reviewing records for accuracy and quality improvement.

Please note:

These tools do not make decisions about your care. All clinical decisions are made by licensed professionals on your care team.
Information used within these platforms is handled in accordance with privacy and confidentiality laws (such as HIPAA).
Our providers review any information generated or supported by these platforms before it is used in your care.
You are welcome to ask questions about these systems at any time.

The use of these tools helps us streamline care and maintain high standards, while your right to receive services is never dependent on whether these tools are utilized.

Medication

If medication is prescribed, you agree to abide by your prescribing practitioner's directions regarding your medication. I will discuss with my prescribing practitioner the effects, including any side effects of my medication.

Benzodiazepines are not preferred in ongoing treatment in our practice. It is at the discretion of the prescribing practitioner if he/she/they feels it is indicated to prescribe benzodiazepines. If applicable, a transition plan and alternatives to this treatment will be provided.

Some medications require monthly appointments to carefully monitor symptoms and effectiveness of treatment.

I agree to not receive concurrent psychiatric medication management services from any other provider while receiving medication treatment from a provider at OMGH. I also agree to inform my provider of any and all psychotropic medications I have been prescribed by any provider while in treatment at OMGH. I authorize my provider to obtain my dispensed medication history, including medications prescribed by another provider.

Financial Responsibility

Financial and payment policies have been outlined separately in the OMHG Financial Policy. Clients should read this form carefully for information pertaining to financial responsibility and payment policies for services with OMHG.

Exceptions to Confidentiality

Please be aware that while we strive to maintain the confidentiality of our clients' records and information, exceptions may apply, and there may be certain situations where we are legally or ethically required to disclose your health records and information.

Certain situations may necessitate this, such as receiving a court order or a valid request from a licensing board or a federal or state agency for information or records. We may also be required to report or disclose information to various entities, including federal or state authorities, licensing boards, agencies, departments, or courts, on occasion.

Whenever feasible, we will strive to notify you if disclosure ever becomes necessary.

Circumstances that may require sharing your information and/or file include, but are not limited to:

Abuse/Neglect: Child neglect and/or abuse, as well as the neglect or abuse of the elderly, disabled, and vulnerable adults.
Duty to Protect: Thoughts, plans, and/or intent to harm self or others (i.e., suicidal or homicidal).
Court Orders and Subpoenas: Orders signed or issued by a judge or court, or by attorneys appointed by a court (such as guardians ad litem or best-interest attorneys).
Complaints/Litigation: In the event of a complaint filed with a licensing board or another state or federal regulatory authority, or in the event of civil litigation initiated by the client against OMHG.
Regulatory Obligations: State and/or Federal regulatory authorities in connection with their compliance or investigatory responsibilities.
Operational and Clinical Purposes: Employees, staff, agents, or others acting on behalf of the practice for operational purposes. Additionally, providers at OMHG may consult with other practitioners to ensure that the best level of care and service is provided.
Supervision Review: Access to your records and information, including treatment details, by a supervising clinician if your therapist is under supervision for their license.

If you have any concerns about your confidentiality, please bring them to our attention promptly so we can address them.

I consent to the use of my information by OMHG for continuity of care and as outlined in their Privacy Practices.

I understand that all providers that are treating me will have access to my clinical information including progress notes and medication management. I acknowledge that there may be occasions where it would be helpful or necessary for my treating provider to communicate with other health care professionals regarding my care and I authorize such communications.

Medical Records

You have the right to request a copy of your medical records or authorize release of your records to a third party (such as another healthcare provider, attorney, or insurance company).

To protect your privacy, we require your written consent before releasing any information. This written consent is provided via signed Release of Information that can be obtained by contacting your provider, calling the main line, or presenting at any OMHG office.

If your provider feels that information can cause emotional harm to you, he/she/they can only release the psychiatric records to a qualified medical professional treating you for the same condition.

Records will be provided within 21 business days of receipt of a valid written request, in accordance with Maryland law. Reasonable fees may apply for copies, mailing, or administrative processing.

Emergency Contact Procedures

Emergencies include any situations where there is a question of danger to your own life or anyone else, or conditions like psychosis, where clients may be incapable of making rational decisions.

In emergency situations, you should go directly to the emergency room. In addition, your provider may require you to go to the nearest emergency room.

If your provider has any concern of imminent danger to yourself or someone else, your provider will also be required to involve the police or medical authorities to transport you to the nearest medical facility for evaluation, sometimes for an extended time (>24 hours).

If I (or my child) experience a mental health crisis, I will contact:

OMHG during business hours
The National Suicide Prevention Lifeline (dial 988) or 911 for immediate assistance outside of office hours

Right to Withdraw Consent

I understand that I may withdraw my consent for evaluation or treatment (for myself or my child) at any time by submitting a written request to OMHG. In the event consent is withdrawn, treatment ends and discharge will occur.

Acknowledgement of Understanding

By signing below, I confirm that:

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

Consent to Participate

I, the client (or parent/guardian, if applicable), voluntarily consent to participate (or allow my child to participate) in:

A mental health evaluation;
Medically appropriate and necessary treatment as recommended by OMHG clinical staff.

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.

Consent for Psychiatric Evaluation and Treatment: GBCC

2026 GBCC Consent for Psychiatric Evaluation and Treatment

Consent for Psychiatric Evaluation and Treatment

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

Client Rights and Responsibilities

As a client receiving psychiatric services at GBCC, you have important rights and responsibilities to help ensure safe, ethical, and effective care. Evaluations and treatments will be conducted by licensed clinical professionals, such as Psychiatric Nurse Practitioners, Psychologists, Social Workers, Therapists, or provisionally licensed providers under supervision, in accordance with applicable state law. Please review the following:

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, including decisions about medications and other interventions.
Be informed of the potential benefits, risks, and alternatives of recommended treatments.
Refuse treatment or request a second opinion, understanding that refusal may affect treatment outcomes.
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 (e.g., risk of harm to self/others, child/elder abuse, court order).
Access your medical records within the timeframe established by Maryland law (21 business days).
File a grievance or complaint about your care 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 and following agreed-upon recommendations.
Taking medications as prescribed and discussing any concerns or side effects with your provider before making changes.
Treating staff and other clients with courtesy and respect.
Keeping scheduled appointments and providing timely notice if you need to cancel or reschedule.
Understanding your insurance coverage and financial responsibility for services.
Informing your provider promptly if your condition changes or if you experience a crisis.

Benefits and Risks of Evaluation and Treatment

Potential Benefits

Reduction in symptoms such as anxiety, depression, or other distressing experiences.
Improved mood, functioning, and quality of life.
Increased ability to manage stress, relationships, and daily responsibilities.
Development of new coping skills and healthier patterns of thinking and behavior.
Enhanced self-awareness and personal growth.

Potential Risks

Psychiatric medications may cause side effects, which can range from mild (e.g., drowsiness, nausea) to more serious (e.g., changes in mood, metabolic effects, or rare but significant medical complications).
It may take time to find the most effective medication and dosage, and adjustments may be necessary.
Psychotherapy may bring up difficult emotions, memories, or increased distress before improvement occurs.
There is no guarantee of specific outcomes, and some individuals may not experience the results they hope for.
In rare cases, treatment may temporarily worsen symptoms, requiring close communication with your provider.

Termination or Discharge

GBCC also reserves the right to terminate treatment given certain circumstances. We will not tolerate violent acts, threats, or harassment towards your provider, their colleagues, or their family. Your provider reserves the right to terminate your treatment unilaterally and immediately in such situations.

Patient Portal

You should schedule an appointment if the issue is too complex or sensitive to discuss via the patient portal. Patient portal is not appropriate for an urgent matter or an emergency situation.

Telehealth Services

Not all insurance companies reimburse for mental health treatment via Telehealth. Fees for sessions rendered via Telehealth are the same as in-person sessions (see financial policy).

You do not need to create an account or download an app to participate in Telehealth sessions. You do need:

Computer, tablet, or smart phone with an external or integrated webcam
An external or integrated microphone
An internet connection with sufficient speed to conduct audio-video sessions. An ethernet cable over Wifi when possible, as well as shutting down all background applications is recommended for the best connection.
A private location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.

Technology based and clinical risks of mental health treatment via Telehealth may include (but are not limited to):

The technology platform dropping due to poor internet connection
Delay in treatment due to connections or other technologies
In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by the provider
In very rare instances, security protocols could fail, causing a breach of privacy of personal health information
Privacy breach from your geographical location or the technology used which is outside of the provider's control
Discomfort with virtual versus in-person sessions
Difficulty interpreting non-verbal communication
Reduced access to immediate resources if risk of self-harm or harm to others becomes apparent

I will not record any telehealth sessions without the prior written consent of GBCC. I understand that GBCC or the practice's providers will not record telehealth sessions without my consent.

I understand that all rules and regulations that apply to clinical practice in the state of Maryland also apply to telehealth.

Use of Third-Party Tools and Platforms

Please note:

These tools do not make decisions about your care. All clinical decisions are made by licensed professionals on your care team.
Information used within these platforms is handled in accordance with privacy and confidentiality laws (such as HIPAA).
Our providers review any information generated or supported by these platforms before it is used in your care.
You are welcome to ask questions about these systems at any time.

The use of these tools helps us streamline care and maintain high standards, while your right to receive services is never dependent on whether these tools are utilized.

Medication

Some medications require monthly appointments to carefully monitor symptoms and effectiveness of treatment.

I agree to not receive concurrent psychiatric medication management services from any other provider while receiving medication treatment from a provider at GBCC. I also agree to inform my provider of any and all psychotropic medications I have been prescribed by any provider while in treatment at GBCC. I authorize my provider to obtain my dispensed medication history, including medications prescribed by another provider.

Financial Responsibility

Financial and payment policies have been outlined separately in the GBCC Financial Policy. Clients should read this form carefully for information pertaining to financial responsibility and payment policies for services with GBCC.

Exceptions to Confidentiality

Whenever feasible, we will strive to notify you if disclosure ever becomes necessary.

Circumstances that may require sharing your information and/or file include, but are not limited to:

Abuse/Neglect: Child neglect and/or abuse, as well as the neglect or abuse of the elderly, disabled, and vulnerable adults.
Duty to Protect: Thoughts, plans, and/or intent to harm self or others (i.e., suicidal or homicidal).
Court Orders and Subpoenas: Orders signed or issued by a judge or court, or by attorneys appointed by a court (such as guardians ad litem or best-interest attorneys).
Complaints/Litigation: In the event of a complaint filed with a licensing board or another state or federal regulatory authority, or in the event of civil litigation initiated by the client against GBCC.
Regulatory Obligations: State and/or Federal regulatory authorities in connection with their compliance or investigatory responsibilities.
Operational and Clinical Purposes: Employees, staff, agents, or others acting on behalf of the practice for operational purposes. Additionally, providers at GBCC may consult with other practitioners to ensure that the best level of care and service is provided.
Supervision Review: Access to your records and information, including treatment details, by a supervising clinician if your therapist is under supervision for their license.

If you have any concerns about your confidentiality, please bring them to our attention promptly so we can address them.

I consent to the use of my information by GBCC for continuity of care and as outlined in their Privacy Practices.

Medical Records

You have the right to request a copy of your medical records or authorize release of your records to a third party (such as another healthcare provider, attorney, or insurance company).

If your provider feels that information can cause emotional harm to you, he/she/they can only release the psychiatric records to a qualified medical professional treating you for the same condition.

Records will be provided within 21 business days of receipt of a valid written request, in accordance with Maryland law. Reasonable fees may apply for copies, mailing, or administrative processing.

Emergency Contact Procedures

Emergencies include any situations where there is a question of danger to your own life or anyone else, or conditions like psychosis, where clients may be incapable of making rational decisions.

In emergency situations, you should go directly to the emergency room. In addition, your provider may require you to go to the nearest emergency room.

If I (or my child) experience a mental health crisis, I will contact:

GBCC during business hours
The National Suicide Prevention Lifeline (dial 988) or 911 for immediate assistance outside of office hours

Right to Withdraw Consent

I understand that I may withdraw my consent for evaluation or treatment (for myself or my child) at any time by submitting a written request to GBCC. In the event consent is withdrawn, treatment ends and discharge will occur.

Acknowledgement of Understanding

By signing below, I confirm that:

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

Consent to Participate

I, the client (or parent/guardian, if applicable), voluntarily consent to participate (or allow my child to participate) in:

A mental health evaluation;
Medically appropriate and necessary treatment as recommended by GBCC clinical staff.

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 Management Clients Only

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.

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.

Miscellaneous Forms - All Clients, As Needed

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 so we can automatically charge any co-pays, co-insurance, deductible amounts, and professional service charges such as late cancellation or missed appointment fees.

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 been posted to your account. Your card will be processed for Self Pay rates if valid insurance information was not provided at the time of service.

ACKNOWLEDGEMENTS & AGREEMENT

I, the client, understand that...

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

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)

Supervisory Disclosure Form

Supervisory Disclosure

SUPERVISORY DISCLOSURE

State of Maryland Rules governing licensed mental health professionals, as well as the National Association of Social Workers (NASW) Standards in Social Work Supervision, the Association for Counselor Education and Supervision Ethical Standards, and the American Psychological Association Ethical Codes require that you be informed that the work of your therapist is being supervised by a licensed or registered professional of the appropriate discipline.

The primary supervisor has full responsibility for the supervised work of their supervisees. To ensure the highest standard of care, supervisors monitor and review the progress of your work with your therapist. The limits of confidentiality outlined 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 Board of Social Work Examiners, the Board of Professional Counselors and Therapists, and the Maryland State Board of Psychology, we would like to inform you that the following therapists are under clinical supervision with the following supervisors:

Clinician Under Supervision	Supervisor
Julia Williams, LMSW	Patricia Itzel, LCSW-C patricia.itzel@orchardmentalhealth.com
Arella Mayer, LMSW
Hannah Miller, LMSW
Aleena Portugal, LGPC	John Volpe, LCPC, NCC john.volpe@orchardmentalhealth.com
Gage Smith, LGPC	John Volpe, LCPC, NCC john.volpe@orchardmentalhealth.com
Zaynub Siddiqui, LGPC	Elisabeth Ferraro, LCPC, NCC elisabeth.ferraro@orchardmentalhealth.com
Daniela Bedon, LGPC	Tracy Swetlow, LCPC tracy.swetlow@orchardmentalhealth.com
Caiwei Tang, LGPC	Tracy Swetlow, LCPC tracy.swetlow@orchardmentalhealth.com
Daniela Gaona, LGPC	Martina Alvarado, LCPC, NCC martina.alvarado@orchardmentalhealth.com
Huaying Jin, LGPC
Ziyi “Winnie” Wu, LGPC
Naweh Diggs, LMSW	Shani Cerritos, LCSW-C shani.cerritos@orchardmentalhealth.com
Temple Price, Ph.D.	Pamela Lubing, Psy.D. pamela.lubing@orchardmentalhealth.com
Amber Smith, Psy.D.	William Strahl, Psy.D. william.strahl@orchardmentalhealth.com
Christa Hill, Ph.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)

Across State Lines Agreement

ACROSS STATE LINES AGREEMENT

Acknowledgement(Required)

I understand that my service provider at Orchard Mental Health Group is not currently licensed in the state I am residing in. As a result, I verify that I am willing to travel to Maryland for on-site services at the provider's office or remain at the following address location during my tele-health appointment:

Address(Required)

Street Address Address Line 2 City State ZIP Code

Untitled(Required)

I understand I will remain at this location in Maryland while attending all virtual appointments with my service provider in compliance with their state license requirements. I also understand that if I am unable to travel to Maryland at the time of my appointment(s), I will not be able to attend the appointment. In these situations, rescheduling efforts will be made when I am again able to travel to the above location in Maryland.

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.

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