Better Mood Clinic Forms

NoteYou will need Adobe Acrobat Reader to view or print the forms listed below.  If you do not have this reader, then you can download it for free at adobe.com.  After you've downloaded the reader, if necessary, click on the forms you'll need.

We've provided forms below that you'll need to complete before your first appointment.  It will take you about 45 minutes to complete these forms.  Simply print the forms and complete them by hand.

Intake Forms 

v   BMC Child Mental Health Intake Form

This form is used to capture information regarding children seeking help. 

v   BMC Adult Mental Health Intake Form

 

  This form is used to capture information regarding adults seeking help

v   Consent to Treatment

This form outlines our commitment to your care.  This form provides general BMC information to include clinic hours, types of appointments, cancellations, insurance, etc.  This form is also used by you to identify who we can release information to such as medical providers and family members involved in the care of the patient.

v  Telephone Intake Form

This form is used to collect demographic and insurance information.

 

v   Gambling Intake Form

This form is used to collect gambling intake information.

v   New Patient Information Sheet

This form captures demographic data about the client (e.g., name, gender, age, etc.) and contact information (e.g., address, phone numbers, emergency contact information, etc.), referral information, etc.

v   Substance Abuse Intake Form (Adult)

This form is used in collecting a substance use and abuse history.

Release Forms 

v   Educational Release

Authorization request to receive educational records.

v   Psychotherapy Release

Authorization request to release and/or receive protected health information. 

v   Medical Release

Authorization request to release and/or receive protected health information

v   Protected Health Information Request

This form is used to request protected health information from a provider.

Other 

v   BMC Psychological Services

Flyer listing psychological services provided by BMC

v   BMC Customs and Courtesies

The Better Mood Clinic of South Georgia, LLC is a therapeutic environment.  This handout outlines BMC guidelines.

v   Interns/Residents Agreement

Patient agreement to allow our interns and residents to provide services, as part of their training.

 

 


           
 

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