app.formdr.com
Open in
urlscan Pro
3.222.153.146
Public Scan
Submitted URL: http://email.formdoctor-mail.com/c/eJwdT8FqwzAU-5rktuA8O7bfwYewLesOpU0prOwybMdZUhrsOu6lXz9nIJAQQkKDMhpGjuWsgACQmlCggLWohONMAlI-CB...
Effective URL: https://app.formdr.com/practice/MTE3MA==/form/5u_ROHhATtXqq9483WcRpCFcQbcI9tP8/P2s2Q45QQpOAbtXujZ6Fz9s7eArzcGjH
Submission: On January 31 via manual from PH — Scanned from DE
Effective URL: https://app.formdr.com/practice/MTE3MA==/form/5u_ROHhATtXqq9483WcRpCFcQbcI9tP8/P2s2Q45QQpOAbtXujZ6Fz9s7eArzcGjH
Submission: On January 31 via manual from PH — Scanned from DE
Form analysis 1 forms found in the DOM
<form class="sc-gTgzIj fTLLNh ">
<div style="display: block; min-height: 100vh; margin: 0px auto;">
<div class="admin-builder-container ">
<div class="sc-dOSReg dPzEQr packet-container" style="background-color: rgb(90, 122, 163);">
<div class="sc-jNMdTA ewqGCM" style="display: block; border-bottom: 3px solid rgb(0, 0, 0); position: relative; background-color: rgb(255, 255, 255); z-index: 3; margin: 0px auto; width: 100%;">
<div class="container flex-row">
<div class="f-logo">
<div class="centered-image"><img src="https://drive.google.com/uc?id=1pP6i2JoRGof79TEuUfFZETEvoG_3wwkI&export=download" style="max-width: 300px;"></div>
</div>
<div class="f-name pull-right" style="color: rgb(51, 51, 51); font-size: 25px;">River's Bend New Patient Forms for 2022</div>
</div>
</div>
<div class="packet-outer-container" style="padding: 30px 15px 70px; max-width: 1170px; margin: 0px auto;">
<div style="width: 100%; display: flex; margin-left: auto; margin-right: auto;">
<header class="MuiPaper-root MuiAppBar-root MuiAppBar-positionStatic MuiAppBar-colorPrimary sc-iBaPrD gdARiY scroll-buttons MuiPaper-elevation4" style="background-color: transparent; box-shadow: none; z-index: 1;">
<div class="MuiTabs-root" style="min-height: 44px;">
<div class="MuiButtonBase-root MuiTabScrollButton-root MuiTabs-scrollButtons MuiTabs-scrollButtonsDesktop Mui-disabled" aria-disabled="false"><svg class="MuiSvgIcon-root MuiSvgIcon-fontSizeSmall" focusable="false" viewBox="0 0 24 24"
aria-hidden="true">
<path d="M15.41 16.09l-4.58-4.59 4.58-4.59L14 5.5l-6 6 6 6z"></path>
</svg><span class="MuiTouchRipple-root"></span></div>
<div class="MuiTabs-scrollable" style="width: 99px; height: 99px; position: absolute; top: -9999px; overflow: scroll;"></div>
<div class="MuiTabs-scroller MuiTabs-scrollable" style="margin-bottom: 0px;">
<div class="MuiTabs-flexContainer" role="tablist"><button class="MuiButtonBase-root MuiTab-root MuiTab-textColorInherit sc-iUuytg esdhrP jss107 active" tabindex="-1" type="button" role="tab"><span class="MuiTab-wrapper">1. Consent
for Treatment</span></button><button class="MuiButtonBase-root MuiTab-root MuiTab-textColorInherit sc-iUuytg esdhrP jss109 " tabindex="-1" type="button" role="tab"><span class="MuiTab-wrapper">2. Consent for Telemedicine
Services</span></button><button class="MuiButtonBase-root MuiTab-root MuiTab-textColorInherit sc-iUuytg esdhrP jss111 " tabindex="-1" type="button" role="tab"><span class="MuiTab-wrapper">3. Privacy
Practices</span></button><button class="MuiButtonBase-root MuiTab-root MuiTab-textColorInherit sc-iUuytg esdhrP jss113 " tabindex="-1" type="button" role="tab"><span class="MuiTab-wrapper">4. Insurance Verification
Form</span></button><button class="MuiButtonBase-root MuiTab-root MuiTab-textColorInherit sc-iUuytg esdhrP jss115 " tabindex="-1" type="button" role="tab"><span class="MuiTab-wrapper">5. Financial Policy</span></button><button
class="MuiButtonBase-root MuiTab-root MuiTab-textColorInherit sc-iUuytg esdhrP jss117 " tabindex="-1" type="button" role="tab"><span class="MuiTab-wrapper">6. PCP Communication</span></button><button
class="MuiButtonBase-root MuiTab-root MuiTab-textColorInherit sc-iUuytg esdhrP jss119 " tabindex="-1" type="button" role="tab"><span class="MuiTab-wrapper">7. Recipient Right's</span></button></div><span
class="jss47 jss49 MuiTabs-indicator" style="left: 0px; width: 211px;"></span>
</div>
<div class="MuiButtonBase-root MuiTabScrollButton-root MuiTabs-scrollButtons MuiTabs-scrollButtonsDesktop" aria-disabled="false"><svg class="MuiSvgIcon-root MuiSvgIcon-fontSizeSmall" focusable="false" viewBox="0 0 24 24"
aria-hidden="true">
<path d="M8.59 16.34l4.58-4.59-4.58-4.59L10 5.75l6 6-6 6z"></path>
</svg><span class="MuiTouchRipple-root"></span></div>
</div>
</header>
</div>
<div>
<div class="sc-bZSQDF eUgDnc " style="background-color: rgb(231, 231, 231); width: 100%; margin-left: auto; margin-right: auto;">
<div class="tab-header">
<div>
<h1 style="color: rgb(153, 153, 153); font-size: 36px; font-family: "Titillium Web"; margin-bottom: -10px; margin-top: 10px; font-weight: 500;">Consent for Treatment</h1>
</div>
</div>
<div class="fields-container" style="background-color: rgb(255, 255, 255);">
<div class="fd-field-container ">
<div class="" style="">
<div class="field-container">
<div class="fd-field-item field-type-title ">
<div style="width: 100%;">
<h2 class="fd-field-item-title" style="font-size: 30px; text-align: left;">Consent to Treatment</h2>
</div>
</div>
</div>
<div class="field-container">
<div class="fd-field-item field-type-columns ">
<div class="fd-field-container ">
<div class="fd-field-item-column">
<div class="column-item columns-number-2 columns-space-undefined">
<div class="field-container">
<div class="fd-field-item field-type-name left-aligned-field">
<div class="fd-field-item-text">
<div class="fd-label-cont"><label>Patient Name <span class="fd-required">*</span></label></div>
<div class="input-list">
<div class="MuiFormControl-root MuiTextField-root MuiFormControl-marginDense MuiFormControl-fullWidth"><label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined" data-shrink="false" style="font-size: 14px;">First Name</label>
<div class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense" style="height: 34px; font-size: 14px;"><input
aria-invalid="false" name="firstName" type="text" datalabel="First Name" class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense" value="">
<fieldset aria-hidden="true" class="jss85 MuiOutlinedInput-notchedOutline">
<legend class="jss87"><span>First Name</span></legend>
</fieldset>
</div>
</div>
<div class="MuiFormControl-root MuiTextField-root MuiFormControl-marginDense MuiFormControl-fullWidth"><label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined" data-shrink="false" style="font-size: 14px;">Middle Name</label>
<div class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense" style="height: 34px; font-size: 14px;"><input
aria-invalid="false" name="middleName" type="text" datalabel="Middle Name" class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense" value="">
<fieldset aria-hidden="true" class="jss85 MuiOutlinedInput-notchedOutline">
<legend class="jss87"><span>Middle Name</span></legend>
</fieldset>
</div>
</div>
<div class="MuiFormControl-root MuiTextField-root MuiFormControl-marginDense MuiFormControl-fullWidth"><label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined" data-shrink="false" style="font-size: 14px;">Last Name</label>
<div class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense" style="height: 34px; font-size: 14px;"><input
aria-invalid="false" name="lastName" type="text" datalabel="Last Name" class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense" value="">
<fieldset aria-hidden="true" class="jss85 MuiOutlinedInput-notchedOutline">
<legend class="jss87"><span>Last Name</span></legend>
</fieldset>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="column-item columns-number-2 columns-space-undefined">
<div class="field-container">
<div class="fd-field-item field-type-date left-aligned-field">
<div class="fd-field-item-date fd-input form-group">
<div class="fd-label-cont"><label>Patient's Birthdate </label></div>
<div class="dt-picker">
<div><select data-field="month">
<option disabled="" value="">Month</option>
<option value="0">January</option>
<option value="1">February</option>
<option value="2">March</option>
<option value="3">April</option>
<option value="4">May</option>
<option value="5">June</option>
<option value="6">July</option>
<option value="7">August</option>
<option value="8">September</option>
<option value="9">October</option>
<option value="10">November</option>
<option value="11">December</option>
</select><select data-field="day">
<option disabled="" value="">Day</option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select><select data-field="year">
<option disabled="" value="">Year</option>
<option value="1900">1900</option>
<option value="1901">1901</option>
<option value="1902">1902</option>
<option value="1903">1903</option>
<option value="1904">1904</option>
<option value="1905">1905</option>
<option value="1906">1906</option>
<option value="1907">1907</option>
<option value="1908">1908</option>
<option value="1909">1909</option>
<option value="1910">1910</option>
<option value="1911">1911</option>
<option value="1912">1912</option>
<option value="1913">1913</option>
<option value="1914">1914</option>
<option value="1915">1915</option>
<option value="1916">1916</option>
<option value="1917">1917</option>
<option value="1918">1918</option>
<option value="1919">1919</option>
<option value="1920">1920</option>
<option value="1921">1921</option>
<option value="1922">1922</option>
<option value="1923">1923</option>
<option value="1924">1924</option>
<option value="1925">1925</option>
<option value="1926">1926</option>
<option value="1927">1927</option>
<option value="1928">1928</option>
<option value="1929">1929</option>
<option value="1930">1930</option>
<option value="1931">1931</option>
<option value="1932">1932</option>
<option value="1933">1933</option>
<option value="1934">1934</option>
<option value="1935">1935</option>
<option value="1936">1936</option>
<option value="1937">1937</option>
<option value="1938">1938</option>
<option value="1939">1939</option>
<option value="1940">1940</option>
<option value="1941">1941</option>
<option value="1942">1942</option>
<option value="1943">1943</option>
<option value="1944">1944</option>
<option value="1945">1945</option>
<option value="1946">1946</option>
<option value="1947">1947</option>
<option value="1948">1948</option>
<option value="1949">1949</option>
<option value="1950">1950</option>
<option value="1951">1951</option>
<option value="1952">1952</option>
<option value="1953">1953</option>
<option value="1954">1954</option>
<option value="1955">1955</option>
<option value="1956">1956</option>
<option value="1957">1957</option>
<option value="1958">1958</option>
<option value="1959">1959</option>
<option value="1960">1960</option>
<option value="1961">1961</option>
<option value="1962">1962</option>
<option value="1963">1963</option>
<option value="1964">1964</option>
<option value="1965">1965</option>
<option value="1966">1966</option>
<option value="1967">1967</option>
<option value="1968">1968</option>
<option value="1969">1969</option>
<option value="1970">1970</option>
<option value="1971">1971</option>
<option value="1972">1972</option>
<option value="1973">1973</option>
<option value="1974">1974</option>
<option value="1975">1975</option>
<option value="1976">1976</option>
<option value="1977">1977</option>
<option value="1978">1978</option>
<option value="1979">1979</option>
<option value="1980">1980</option>
<option value="1981">1981</option>
<option value="1982">1982</option>
<option value="1983">1983</option>
<option value="1984">1984</option>
<option value="1985">1985</option>
<option value="1986">1986</option>
<option value="1987">1987</option>
<option value="1988">1988</option>
<option value="1989">1989</option>
<option value="1990">1990</option>
<option value="1991">1991</option>
<option value="1992">1992</option>
<option value="1993">1993</option>
<option value="1994">1994</option>
<option value="1995">1995</option>
<option value="1996">1996</option>
<option value="1997">1997</option>
<option value="1998">1998</option>
<option value="1999">1999</option>
<option value="2000">2000</option>
<option value="2001">2001</option>
<option value="2002">2002</option>
<option value="2003">2003</option>
<option value="2004">2004</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2009</option>
<option value="2010">2010</option>
<option value="2011">2011</option>
<option value="2012">2012</option>
<option value="2013">2013</option>
<option value="2014">2014</option>
<option value="2015">2015</option>
<option value="2016">2016</option>
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
</select></div>
</div>
</div>
</div>
</div>
</div>
<div class="column-item columns-number-2 columns-space-undefined">
<div class="field-container">
<div class="fd-field-item field-type-text left-aligned-field">
<div class="fd-field-item-text">
<div class="fd-label-cont"><label>Patient or Parent/Guardian Phone Number </label></div>
<div class="input-list">
<div class="MuiFormControl-root MuiTextField-root MuiFormControl-marginDense MuiFormControl-fullWidth">
<div class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense" style="height: 34px; font-size: 14px;"><input
aria-invalid="false" name="MhtgjfmCpl" type="text" datalabel="" class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense" value="">
<fieldset aria-hidden="true" class="jss85 MuiOutlinedInput-notchedOutline" style="padding-left: 8px;">
<legend class="jss86" style="width: 0.01px;"><span></span></legend>
</fieldset>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="column-item columns-number-2 columns-space-undefined">
<div class="field-container">
<div class="fd-field-item field-type-dropdown left-aligned-field">
<div style="flex-grow: 1;">
<div class="fd-input form-group">
<div class="fd-label-cont"><label>Dropdown </label></div>
<div class="MuiFormControl-root" style="min-width: 97px; margin: 4px;">
<div class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense" style="max-height: 36px;">
<div class="MuiSelect-root MuiSelect-select MuiSelect-selectMenu MuiSelect-outlined MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense" tabindex="0"
role="button" aria-haspopup="listbox" aria-labelledby="fd-select-outlined-label fd-select-outlined" id="fd-select-outlined"><span></span></div><input name="eBZPYeGrpD" aria-hidden="true" tabindex="-1"
class="MuiSelect-nativeInput" value=""><svg class="MuiSvgIcon-root MuiSelect-icon MuiSelect-iconOutlined" focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path d="M7 10l5 5 5-5z"></path>
</svg>
<fieldset aria-hidden="true" class="jss85 MuiOutlinedInput-notchedOutline" style="padding-left: 8px;">
<legend class="jss86" style="width: 0.01px;"><span></span></legend>
</fieldset>
</div>
</div>
</div>
<div></div>
</div>
</div>
</div>
</div>
<div class="column-item columns-number-2 columns-space-undefined">
<div class="field-container">
<div class="fd-field-item field-type-text left-aligned-field">
<div class="fd-field-item-text">
<div class="fd-label-cont"><label>Address </label></div>
<div class="input-list">
<div class="MuiFormControl-root MuiTextField-root MuiFormControl-marginDense MuiFormControl-fullWidth">
<div class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense" style="height: 34px; font-size: 14px;"><input
aria-invalid="false" name="qpucEIxiRB" type="text" datalabel="" class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense" value="">
<fieldset aria-hidden="true" class="jss85 MuiOutlinedInput-notchedOutline" style="padding-left: 8px;">
<legend class="jss86" style="width: 0.01px;"><span></span></legend>
</fieldset>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="field-container">
<div class="fd-field-item field-type-paragraph ">
<div class="ql-editor" style="font-family: inherit; width: 100%;">
<h4><strong>Recipient's Rights</strong></h4>
<p>I certify that I have received the "Know Your Rights" pamphlet available at River's Bend P.C. and certify that I have read and understand its content. I understand that as a recipient of services, I may get more
information about my rights from my Program Rights Advisor: <em>Amy Buchanan, abuchanan@riversbendpc.com, 248-585-3239</em></p>
<p><br></p>
<h4><strong>Non-Voluntary Discharge from Treatment</strong></h4>
<p>A client may be terminated from the program non-voluntarily by the therapist: (A) If the client exhibits physical violence, verbal abuse, carries weapons, or engages in illegal activity at the clinic. (B) If the client
refuses to comply with stipulated program and case protocol or refuses to comply with treatment recommendations. The client will be notified of a non-voluntary discharge by the client's therapist but this is seen as a last
resort when other less drastic measures have proven ineffective. The client may appeal this decision with the program director, or request to re-apply for services at a later date.</p>
<p><br></p>
<h4><strong>Client Notice of Confidentiality</strong></h4>
<ul>
<li>The confidentiality of patient records maintained by the program is protected by federal law and regulations. Generally, the program may not inform a person outside the program that a patient attends the program, or
disclose any information identifying a patient as chemicallly dependent, unless, (1) The patient consents in writing; (2) The disclosure is allowed by a court order, or; (3) The disclosure is made to medical personnel in
a medical emergency or to qualified personnel for research, audit, or program evaluation.</li>
<li>Violation of the Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. </li>
<li class="ql-align-justify">Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to
commit such crime.</li>
</ul>
<p class="ql-align-justify"><br></p>
<h4 class="ql-align-justify"><strong>I acknowledge that the undersigned hereby attests that I am voluntarily authorizing treatment for myself or for my, dependent with the staff at River's Bend, P.C. Further, I consent
to have treatment provided by a Therapist, Psychiatrist or Nurse Practitioner under the supervision of the medical director. I understand that therapy may be discontinued at any time by either party; however, we
recommend that discharge planning and re-entry into the program should it be needed again at a later date.</strong></h4>
</div>
</div>
</div>
<div class="field-container">
<div class="fd-field-item field-type-columns ">
<div class="fd-field-container ">
<div class="fd-field-item-column">
<div class="column-item columns-number-3 columns-space-undefined">
<div class="field-container">
<div class="fd-field-item field-type-signature left-aligned-field">
<div class="fd-label-cont"><label>Client, Parent or Guardian Signature <span class="fd-required">*</span></label></div>
<div style="display: flex; flex-direction: column; width: inherit;">
<div style="max-width: 330px; width: 100%; height: 170px; border: 1px solid rgb(220, 220, 220); display: flex; flex-direction: column;"><canvas width="330" height="140" style="touch-action: none;"></canvas>
<div class="btn-group btn-group-justified" role="group" style="display: flex; flex-direction: row; width: 100%;">
<a role="button" class="btn btn-default" style="background-color: rgb(230, 230, 230); flex-grow: 1; text-align: center; padding: 4px;">Clear</a><a role="button" class="btn btn-default" style="background-color: rgb(230, 230, 230); flex-grow: 1; text-align: center; padding: 4px;">Undo</a>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="column-item columns-number-3 columns-space-undefined">
<div class="field-container">
<div class="fd-field-item field-type-date left-aligned-field">
<div class="fd-field-item-date fd-input form-group">
<div class="fd-label-cont"><label>Date <span class="fd-required">*</span></label></div>
<div class="dt-picker">
<div><select data-field="month">
<option disabled="" value="">Month</option>
<option value="0">January</option>
<option value="1">February</option>
<option value="2">March</option>
<option value="3">April</option>
<option value="4">May</option>
<option value="5">June</option>
<option value="6">July</option>
<option value="7">August</option>
<option value="8">September</option>
<option value="9">October</option>
<option value="10">November</option>
<option value="11">December</option>
</select><select data-field="day">
<option disabled="" value="">Day</option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select><select data-field="year">
<option disabled="" value="">Year</option>
<option value="1900">1900</option>
<option value="1901">1901</option>
<option value="1902">1902</option>
<option value="1903">1903</option>
<option value="1904">1904</option>
<option value="1905">1905</option>
<option value="1906">1906</option>
<option value="1907">1907</option>
<option value="1908">1908</option>
<option value="1909">1909</option>
<option value="1910">1910</option>
<option value="1911">1911</option>
<option value="1912">1912</option>
<option value="1913">1913</option>
<option value="1914">1914</option>
<option value="1915">1915</option>
<option value="1916">1916</option>
<option value="1917">1917</option>
<option value="1918">1918</option>
<option value="1919">1919</option>
<option value="1920">1920</option>
<option value="1921">1921</option>
<option value="1922">1922</option>
<option value="1923">1923</option>
<option value="1924">1924</option>
<option value="1925">1925</option>
<option value="1926">1926</option>
<option value="1927">1927</option>
<option value="1928">1928</option>
<option value="1929">1929</option>
<option value="1930">1930</option>
<option value="1931">1931</option>
<option value="1932">1932</option>
<option value="1933">1933</option>
<option value="1934">1934</option>
<option value="1935">1935</option>
<option value="1936">1936</option>
<option value="1937">1937</option>
<option value="1938">1938</option>
<option value="1939">1939</option>
<option value="1940">1940</option>
<option value="1941">1941</option>
<option value="1942">1942</option>
<option value="1943">1943</option>
<option value="1944">1944</option>
<option value="1945">1945</option>
<option value="1946">1946</option>
<option value="1947">1947</option>
<option value="1948">1948</option>
<option value="1949">1949</option>
<option value="1950">1950</option>
<option value="1951">1951</option>
<option value="1952">1952</option>
<option value="1953">1953</option>
<option value="1954">1954</option>
<option value="1955">1955</option>
<option value="1956">1956</option>
<option value="1957">1957</option>
<option value="1958">1958</option>
<option value="1959">1959</option>
<option value="1960">1960</option>
<option value="1961">1961</option>
<option value="1962">1962</option>
<option value="1963">1963</option>
<option value="1964">1964</option>
<option value="1965">1965</option>
<option value="1966">1966</option>
<option value="1967">1967</option>
<option value="1968">1968</option>
<option value="1969">1969</option>
<option value="1970">1970</option>
<option value="1971">1971</option>
<option value="1972">1972</option>
<option value="1973">1973</option>
<option value="1974">1974</option>
<option value="1975">1975</option>
<option value="1976">1976</option>
<option value="1977">1977</option>
<option value="1978">1978</option>
<option value="1979">1979</option>
<option value="1980">1980</option>
<option value="1981">1981</option>
<option value="1982">1982</option>
<option value="1983">1983</option>
<option value="1984">1984</option>
<option value="1985">1985</option>
<option value="1986">1986</option>
<option value="1987">1987</option>
<option value="1988">1988</option>
<option value="1989">1989</option>
<option value="1990">1990</option>
<option value="1991">1991</option>
<option value="1992">1992</option>
<option value="1993">1993</option>
<option value="1994">1994</option>
<option value="1995">1995</option>
<option value="1996">1996</option>
<option value="1997">1997</option>
<option value="1998">1998</option>
<option value="1999">1999</option>
<option value="2000">2000</option>
<option value="2001">2001</option>
<option value="2002">2002</option>
<option value="2003">2003</option>
<option value="2004">2004</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2009</option>
<option value="2010">2010</option>
<option value="2011">2011</option>
<option value="2012">2012</option>
<option value="2013">2013</option>
<option value="2014">2014</option>
<option value="2015">2015</option>
<option value="2016">2016</option>
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
</select></div>
</div>
</div>
</div>
</div>
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</form>Text Content
River's Bend New Patient Forms for 2022 1. Consent for Treatment2. Consent for Telemedicine Services3. Privacy Practices4. Insurance Verification Form5. Financial Policy6. PCP Communication7. Recipient Right's CONSENT FOR TREATMENT CONSENT TO TREATMENT Patient Name * First Name First Name Middle Name Middle Name Last Name Last Name Patient's Birthdate MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay01020304050607080910111213141516171819202122232425262728293031Year19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027 Patient or Parent/Guardian Phone Number Dropdown Address RECIPIENT'S RIGHTS I certify that I have received the "Know Your Rights" pamphlet available at River's Bend P.C. and certify that I have read and understand its content. I understand that as a recipient of services, I may get more information about my rights from my Program Rights Advisor: Amy Buchanan, abuchanan@riversbendpc.com, 248-585-3239 NON-VOLUNTARY DISCHARGE FROM TREATMENT A client may be terminated from the program non-voluntarily by the therapist: (A) If the client exhibits physical violence, verbal abuse, carries weapons, or engages in illegal activity at the clinic. (B) If the client refuses to comply with stipulated program and case protocol or refuses to comply with treatment recommendations. The client will be notified of a non-voluntary discharge by the client's therapist but this is seen as a last resort when other less drastic measures have proven ineffective. The client may appeal this decision with the program director, or request to re-apply for services at a later date. CLIENT NOTICE OF CONFIDENTIALITY * The confidentiality of patient records maintained by the program is protected by federal law and regulations. Generally, the program may not inform a person outside the program that a patient attends the program, or disclose any information identifying a patient as chemicallly dependent, unless, (1) The patient consents in writing; (2) The disclosure is allowed by a court order, or; (3) The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. * Violation of the Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. * Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such crime. I ACKNOWLEDGE THAT THE UNDERSIGNED HEREBY ATTESTS THAT I AM VOLUNTARILY AUTHORIZING TREATMENT FOR MYSELF OR FOR MY, DEPENDENT WITH THE STAFF AT RIVER'S BEND, P.C. FURTHER, I CONSENT TO HAVE TREATMENT PROVIDED BY A THERAPIST, PSYCHIATRIST OR NURSE PRACTITIONER UNDER THE SUPERVISION OF THE MEDICAL DIRECTOR. I UNDERSTAND THAT THERAPY MAY BE DISCONTINUED AT ANY TIME BY EITHER PARTY; HOWEVER, WE RECOMMEND THAT DISCHARGE PLANNING AND RE-ENTRY INTO THE PROGRAM SHOULD IT BE NEEDED AGAIN AT A LATER DATE. Client, Parent or Guardian Signature * ClearUndo Date * MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay01020304050607080910111213141516171819202122232425262728293031Year19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027 Next Form Save and Continue Later