Barrington Behavioral Health and Wellness Intake Forms

Senior Intake

Preparing for your first appointment is easy!
If you are bringing a senior with you for their first appointment, and you are the Power of Attorney, please download and fill out all the forms below and bring them with you to the 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

Link to Barrington Behavioral Health and Wellness General Intake Questionnaire

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

Adult Questionnaire

Link to Barrington Behavioral Health and Wellness General Intake Questionnaire

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

Consent for Treatment

Powers of Attorney will fill out this form and remit it to our offices as soon as possible.

Payment Authorization

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

HIPAA Notification

Link to Barrington Behavioral Health and Wellness General Intake Questionnaire

Your rights under the Health Information Portability and Accountability Act

HIPAA Agreement

Link to Barrington Behavioral Health and Wellness General Intake Questionnaire

Download and sign the HIPAA Agreement after reading the HIPAA Form

Release of Information

Authorization for release of Mental Health, Alcohol & Drug Abuse and other personal health information

Email Waiver

Election to receive unsecure text or email communications from BBHW.

Consent for Teletherapy

Complete the “Telepsychological Services” checklist if you intend to take part in teletherapy sessions

No Surprises Letter

Download this letter to learn our responsibilty to you under the No Surprises Act.

Good Faith Estimate

Brenda Danielson, Psy. D., LCP, works with adults across the lifespan with a specialty in women’s mental health, trauma, grief and loss, and co-occurring disorders. She is certified in several evidence-based therapies including CPT, CBT, CBT-I and ROSES. Call to make an appointment: 888-261-2178

Download this form for your reference and your therapist will discuss this with you.

Private Pay Contract

If you intend to pay “Out Of Pocket” (fee for service), download this form and complete it and remit it to BBHW prior to your next appointment.

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

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Contact us today to schedule your first appointment!