PATIENT INTAKE FORM

PERSONAL INFORMATION

INSURANCE INFORMATION

MEDICAL & MENTAL HEALTH HISTORY

Primary Healthcare Provider

Psychiatrist or Therapist

Substance Use History

BEHAVIORAL & SOCIAL ASSESSMENT

Employment & Education

CONSENT & CLIENT RIGHTS

A. GENERAL CONSENT FOR TREATMENT

I, voluntarily consent to receive assessment, evaluation, and treatment from

Absolute Care, Inc. I understand that:

My treatment plan will be individualized and based on my needs.

I have the right to refuse or withdraw from treatment at any time.

Treatment may include counseling, therapy, case management, medication management, psychiatric rehabilitation, and

referrals to external services.

Services may be provided in person, via telehealth, or in a group setting as appropriate.

B. CONSENT TO SHARE INFORMATION

Absolute Care, Inc. follows HIPAA & CARF regulations regarding Protected Health Information (PHI).

I authorize Absolute Care, Inc. to release, obtain, or exchange my health information with:

This authorization remains in effect until revoked in writing.

C. CONSENT FOR TELEHEALTH & ELECTRONIC COMMUNICATION

Absolute Care, Inc. may provide virtual sessions via telehealth when appropriate.

I understand that telehealth is not a substitute for emergency care.

I agree to use secure communication methods (e.g., HIPAA-compliant video, encrypted emails).

I understand that Absolute Care, Inc. is not responsible for technical failures affecting my sessions.

D. CONSENT FOR TEXT MESSAGES, EMAILS & PHONE CALLS

Absolute Care, Inc. may use my phone number, email, or text messages to:

- Send appointment reminders.

- Provide treatment-related updates.

- Share educational materials about my care.

I understand that:

Text messages and emails are NOT secure for sensitive health information.

I am responsible for updating my contact preferences if they change.

I can opt out at any time by notifying Absolute Care, Inc. in writing.

I consent to receive text messages, emails, and phone calls.

E. CONSENT FOR RELEASE OF MEDICAL & PSYCHIATRIC RECORDS

I understand that my medical and mental health records are confidential. Absolute Care, Inc. will only release my records

under the following circumstances:

I authorize the release of my information under the following circumstances: if I request a copy for personal use, if required by law enforcement, child protective services, or public safety officials, if needed to process insurance claims, if requested by my court-ordered legal representative, or if released to my family or support system (with my permission above).

This authorization expires one year from today, unless revoked in writing.

F. CONSENT FOR PARTICIPATION IN GROUP SESSIONS & PUBLIC SETTINGS

Absolute Care, Inc. offers group therapy, community-based services, and public events.

Group Sessions: I understand that confidentiality is encouraged but cannot be guaranteed in a group setting.

Public Events: I understand that Absolute Care, Inc. may hold educational or community events, and I may choose to

participate or decline.

G. CONSENT FOR MEDICATION MANAGEMENT (IF APPLICABLE)

If I am prescribed medication as part of my treatment:

I understand the benefits, risks, and potential side effects.

I will communicate any adverse reactions to my provider immediately.

I have the right to discuss alternative treatments if I am uncomfortable with my medication plan.

H. CLIENT RIGHTS & RESPONSIBILITIES

Welcome to Absolute Care Inc

We are committed to supporting your mental health and wellness through respectful, ethical, and individualized care. This document outlines your rights and responsibilities while receiving services from our team.

Understanding Our Services

Absolute Care Inc. provides therapeutic, psychiatric and rehabilitative services designed to help you improve your mental wellness and increase independence.

• PRP (Psychiatric Rehabilitation Program) is designed to teach you life skills and help you move from crisis to stability and independence. Your PRP counselor is here to guide, not to do everything for you. Their role is to support and teach — not replace — your own ability to manage appointments, advocate for yourself, or navigate resources. Over-reliance on your PRP counselor may indicate a need to reevaluate your goals or readiness for services.

  • You may qualify for up to six PRP visits per month, depending on your treatment plan.

  • Important: To continue receiving PRP services, you must also be actively engaged in therapy or medication management. PRP is not a standalone service — it is designed to reinforce your clinical treatment.

• Therapy is a space for emotional support, skill-building, and personal growth. It is not for medication renewals or crisis-only use. If you are receiving medication management, you may be required to participate in regular therapy sessions — typically once or twice per month, depending on your provider’s recommendation.

• Medication Management is provided by licensed professionals who use clinical judgment to prescribe or adjust medications. These services are not guaranteed on demand and require active participation in treatment. 

  • Note: Active participation in therapy is often recommended and may be required to continue receiving medication support.

These services are designed to work together. Participation in only one service, without follow-through on others, may result in your treatment plan being paused or discontinued.

Your Rights

As a client of Absolute Care Inc., you have the right to:

• Be treated with dignity and respect by all staff

• Receive services in a safe, non-discriminatory environment

• Participate in decisions about your treatment plan

• Privacy and confidentiality of your health and personal information

• Request clarification or refuse services without retaliation

• File a complaint without fear of negative consequences

Appointments & Cancellations

• We require 48 hours’ notice for cancellations. Your clinician’s time is valuable, and your appointment could be given to another client in need. Missed or late cancellations affect the whole community.

• If you miss 3 consecutive appointments without contact, or cancel frequently without notice, you may be discharged.

Communication & Boundaries

• Absolute Care Inc. maintains a zero-tolerance policy for threats or aggressive behavior toward staff or other clients. Any threat — verbal, physical, or implied — will result in immediate discharge from all services. We are committed to maintaining a safe and supportive environment for all.

• To ensure fair and effective care for all, clients are expected to communicate with their providers within the boundaries discussed during treatment planning.

• Excessive communication (e.g., calling or texting a PRP counselor multiple times per day) is not appropriate and may result in corrective action or discharge.

• Staff members must maintain professional boundaries to support their own well-being and serve all clients effectively.

• Communication should be limited to appropriate times and in line with what has been agreed upon with your provider.

Grounds for Discharge

Clients may be discharged from Absolute Care Inc. services for the following reasons:

• Making threats toward staff or other clients

• Repeated missed appointments (e.g., 3 consecutive no-shows or excessive cancellations)

• Inappropriate or excessive communication that interferes with staff duties or violates agreed-upon boundaries

• Disrespectful, abusive, or disruptive behavior

• Non-participation in treatment or failure to follow treatment plans

• Violation of clinic policies

Our goal is to provide high-quality care to those who are engaged and respectful of the process. Discharge decisions are made with consideration of your progress, behavior, and overall commitment to your care plan.

Acknowledgment

By signing below, you confirm that you have received, read, and understood your rights and responsibilities while receiving services at Absolute Care Inc.