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

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

Link to Barrington Behavioral Health and Wellness General Intake Questionnaire
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.

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 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.

Teletherapy Consent

Download and sign the ‘Teletherapy Consent’ if you intend to take part in teletherapy 

Thumbnail image of the pdf fill in form for consent to participate in teletherapy sessions with a therapist from Barrington Behavioral Health and Wellness. Questions, call 888-261-2178
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 today to schedule your first appointment!

%d bloggers like this: