Barrington Behavioral Health and Wellness Intake Forms

Adult Intake

Preparing for your first appointment is easy!

If you are visiting with us for the first time, please download and fill out all the forms below and bring them with you to your first appointment.

If you cannot download, complete these forms, and bring them with you to your first appointment you may fill out copies at our offices.

Please allow extra time during your first visit to fill out these forms.

Client Registration

If you are an adult , please fill out this form and bring it to the first appointment.

Adult Intake Questionnaire

Please fill out the Adult History Form and bring it to the first appointment.

Consent for Treatment

All clients must fill out this form and bring it with them to their first appointment.

Payment Authorization

All clients must fill out this form and bring it with them to their first appointment.

BBHW Credit Card Authorization Form

HIPAA Notification

Your rights under the Health Information Portability and Accountability Act

This document is for you information and outlines your rights and BBHW's responsibilities in regard to HIPAA and your privacy.

HIPAA Agreement

Download and sign the HIPAA Agreement after reading the HIPAA Form

This document is for you information and outlines your rights and BBHW's responsibilities in regard to HIPAA and your privacy.

Handy ‘Zip’ File

All the ‘Adult Intake’ forms in one ‘zip’ file!

If you are having trouble or questions you may call our offices at: 888-261-2178

Don't Be Shy. Get In Touch.

Contact us to schedule your free 30 minute assessment

Contact Us
Share This
%d bloggers like this: