Please bring your insurance card and driver s license/identification card.

Transcription

1 New Patient Paperwork Mental Health Clinician Team Dr. Pedro Guimaraes Psychiatrist and Medical Director Elisabeth Ganiron, PsyD. - Child, Adolescent, and Adult Psychologist Mary Meiselman, N.P. Bianca Iglesias, PA-C Amanda Selman, RN Lisa Ratteree, LVN Driving Directions from South: Take 101 North Take Oak Park Rd. exit Continue straight onto Camino Mercado Turn right into the Oak Park Professional Centre We are in the first suite on the right, Suite 536 Driving Direction from North: Take 101 South Take Oak Park Rd. exit Turn left on El Camino Real Turn left onto Oak Park Blvd. (use the middle turn lane) Turn right onto W. Branch St. Turn left onto Camino Mercado Turn right into the Oak Park Professional Centre We are in the first suite on the right, Suite 536 Please review and complete the following forms and agreements, and bring them with you to your initial psychiatric appointment. Please expect that it will take approximately 90 minutes for your initial appointment. Please bring your insurance card and driver s license/identification card. Please be prepared to pay your co-pay on the date of service. Please note that if you are unable to provide your insurance card, you will be responsible to pay in full for the provided services. You must confirm your initial psychiatric appointment 1 business day prior to your appointment with the Front Office. If you do not confirm your appointment, it will be cancelled. If you have not completed the Clinical History Form, Adult/Child Symptom Screener, and PHQ 9 screener through your patient portal prior to your appointment, a trained Clinical Assistant to our Providers will assist you in completing the paperwork.

2 PATIENT INFORMATION Date: Name (Last Name, First Name): SSN: Sex: F M Birth date: Age: Marital Status: Spouse/Partner Name: Primary Phone: OK to leave health related message: Y Secondary Phone: OK to leave health related message: Y N N Physical Address: Mailing Address: Referred by: Employer: Occupation: Employer Phone: Emergency Contact: Relationship to patient: Phone: Preferred Language (Please circle): English Other Decline to Answer Race (Please circle): American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific IslanderWhite Other Decline to Answer Ethnicity (Please circle): Not Hispanic Hispanic Other Decline to Answer INSURANCE INFORMATION: PRIMARY Name of Insured: Relationship to patient: Birth Date: SSN: Insurance Name: ID/Policy # Insurance Phone Number: INSURANCE INFORMATION: SECONDARY Name of Insured: Relationship to patient: Birth Date: SSN: Insurance Name: ID/Policy # Insurance Phone Number: RESPONSIBLE PARTY (IF OTHER THAN THE PATIENT) Responsible Party Name: Relationship to patient: Responsible Party Address: Responsible Party Phone Number: Do we have permission to speak to the responsible party regarding billing? : Y N

3 MEDICATION CHECKLIST Please thoroughly review the medications listed below and mark whether you currently take or had previously taken the medication. If previously taken, please list the reason for discontinuing. Please include any that have been used recreationally. Medication Abilify (aripiprazole) Adderall Ambien (zolpidem) Anafranil (clomipramine) Antabuse (disulfiram) Ativan (lorazepam) Benadryl (diphenhydramine) Buspar (buspirone) Campral (acamprosate) Catapres (clonidine) Celexa (citalopram) Clozaril (clozapine) Codeine Concerta Contrave Cymbalta (duloxetine) Cytomel Depakote (valporic acid) Dexedrine Spansules Dilaudid Doxepin (sinequan) Effexor (venlafaxine) Elavail (amitriptyline) Fanapt (iloperidone) Fiornal Focalin Gabitril Geodon (ziprasidone) Haldol (haloperidol) Intuniv Invega (paliperidone) Keppra Klonopin (clonazepam) Lamictal (limotragine) Latuda Lexapro (escitalopram) Librium (chlordiazepoxide) Lithboid Lithium Lunesta (eszopiclone) Luvox (fluvoxamine) Lyrica (pregabalin) Melatonin Mellaril (thioridazine) Current Previous Reason for Discontinuing Medication Methadone Morphine (MS Contin) Navane (thiothixene hcl) Neurontin (gabapentin) Norco (hydro +acet) Orap (pimozide) Oxycodone Pamelor (nortriptyline) Paxil (paroxetine) Percocet (oxy + acet) Phentermine Pristiq (desvenlafaxine) Propanolol Provigil (modafinil) Prozac (fluoxetine) Remeron (mirtazapine) Restoril (tempazepam) Revia (naltrexone) Risperdal (risperidone) Ritalin (methylphenidate) Rozerem (ramelteon) Seroquel (quetiapine) Serzone (nefazidone) Sinequan (doxepin) Sonata (zaleplon) Stelazine (trifluoperazine) Strattera (atomoxetine) Suboxone (buprenorphine) Subutex (buprenorphine) Tegretol (carbamazepine) Tenex (guanfacine) Thorazine(chlorpromazine) Topamax (topiramate) Trazadone (desyrel) Trileptal (oxcarbazepine) Valium (diazepam) Vicodin (hydro+acet) Viibryd (vilazodone) Vistaril (hydroxyzine hcl) Vyvanse Wellbutrin (bupropion) Xanax (alprazolam) Zoloft (sertraline) Zyprexa (olanzapine) Current Previous Reason for Discontinuing

4 FEE STATUS AND CONSENT TO TREATMENT Name: DOB: Date: Welcome to Central Coast Behavioral Health, Inc. We are a corporation intended to enhance ones mental health and wellness. We do this by working as a team and incorporating several medical and mental health professional s experience and expertise, in order to provide the client with the best well rounded care. Our goal is to work together and provide our patients the ability to gain and maintain well ness, promoting growth and development. As a patient of the clinic, I understand that my mental health professional may discuss my care with other professionals within the clinic in order to provide me with the best care. I hereby give my consent for my mental health professional to consult with other professionals within the clinic. I acknowledge that I have been informed of my rights as a client of Central Coast Behavioral Health, Inc. and will be given the opportunity to participate in the development of my own treatment plan. The nature of the treatment for which the treatment plan calls will be explained to me as well as the reason for that treatment and the expected risks and benefits which that treatment might bring me. I understand that Central Coast Behavioral Health INC cannot give me any guarantees about the results of treatment and has given me no implicit warranty that the proposed treatment will improve the condition of my life. I also understand that I can terminate my treatment by notifying Central Coast Behavioral Health, Inc. Insurance Release: I hereby authorize the office of Central Coast Behavioral Health, Inc. and Billing Agency to release any necessary information to my insurance carrier for claim submission and/or continued care. I authorize payment for services rendered to be sent directly to Dr. Pedro Guimaraes for any benefits available under my insurance plan. I understand that I am financially responsible for any coinsurance amount (deductible, co-pay, etc.) and any balance (patient responsibility, self-pay, etc.) for services rendered. I authorize Dr. Pedro Guimaraes to retain my signature on file for the purpose of claim submission. I hereby agree to these terms and conditions, the no show/cancelation policy and consent for treatment. Notice to Consumers: Medical doctors are licensed and regulated by the Medical Board of California, (800) , I certify that the information given by me is true and correct and to the best of my knowledge I authorize release of all records required to act on requests for payment from any and all third party sources. I understand that it is my responsibility to obtain any insurance pre-authorization and verify my insurance benefits. I request payment of any authorized benefits be made on my behalf. I understand and agree to make best efforts to assist and secure payments for services under any insurance coverage available to me. I understand that I am responsible for any deductions from payments due to Central Coast Behavioral Health INC because of limitations in my existing insurance coverage or my current financial status. I understand that the following services are charged directly to me: Letter (school, work leave/return, misc.) $15 Family Medical Leave Forms $20 Medical Records: For Patients & Lawyers $30 School Disability Forms $15 Disability Online and Paper Forms: Initial $30 No show or cancellation within 24 hours of appt $115 Disability Online and Paper Forms: Supplemental $20 Returned check fee $25 I understand that I have the responsibility to keep all scheduled appointments and, if necessary, to cancel appointments at least 24 hours in advance. No shows or cancellations within 24 hours of the appointment will be charged $115. Printed Name of Patient or Legal Guardian Signature of Patient or Legal Guardian Date

5 CONSENT & AGREEMENT FOR PSYCHOTROPHIC MEDICATIONS Please read this form carefully. If you have problems reading it, ask to have it read to you. Central Coast Behavioral Health, Inc. met with me and we discussed my symptoms and mental problems that led me to seek a psychiatric treatment at this time. Central Coast Behavioral Health, Inc. told me of medications that are known to help in treating the symptoms and mental problems such as mine. They also discussed with me the risks and benefits of such medications and the likelihood of my improving or not, with or without medication. Central Coast Behavioral Health, Inc. told me the medication(s) I will be taking from the group(s) below. The doctor explained to me the side effects these medications may cause. These side effects, include, but are not limited to: Drug and Side Effect Categories: A. Antipsychotics: drowsiness, stiffness, muscle spasm, tremor, restlessness, dry mouth, constipation, blurry vision, uncontrollable body movements (tardive dyskinesia), weight gain, increase risk for diabetes or elevated lipids (cholesterol), light headedness, drooling, worsening of seizures, changes in blood pressure. B. Antidepressants: dry mouth, constipation, drowsiness, light headedness, heart arrhythmia, nausea, diarrhea, decreased sex drive and function, headache, shakiness, restlessness, unsteadiness, weight gain, worsening of seizures, changes in blood pressure. C. Mood stabilizers/anticonvulsant: sedation, slowed thinking, unsteadiness, nausea, diarrhea, constipation, drooling, increase in liver enzymes, lowering of blood count, rash, changes in blood pressure, increased thirst and urination, decrease in thyroid function. D. Sedatives/anxiolytics: sleepiness, light-headedness, unsteadiness, confusion, blurred vision, slurred speech, nasal congestion and dryness, dry mouth, constipation. E. Antiparkinsonian drugs: dry mouth, constipation, blurry vision, slowed urination, excitation. Patient Agreement for Prescribed Medications Central Coast Behavioral Health, Inc. has informed me of the following rules that apply when taking these medications. This information is very important for your safety, well-being, and successful management for your condition. A. I will not share this/these medication(s), nor use previously prescribed medication or others medications. B. I understand lost or stolen medications or prescriptions will not be replaced. C. I understand that early refill requests will be denied and may be considered a violation of this agreement. D. I understand that medication refill requests must be submitted at least 48 hours in advance. E. I understand that disruptive behavior or threats (or the appearance of this) toward staff and/or other patients will not be tolerated and will result in termination of care from Central Coast Behavioral Health, Inc. Disruptive behavior can include excessive phone calling. Central Coast Behavioral Health, Inc. has explained to me that I have the right to accept or refuse medication(s) recommended for me. I have read and agree to the Patient Agreement for Prescribed Medications. I understand that if I have any further questions or want to know more about my medication(s), I can ask for more information. Printed Name of Patient or Legal Guardian Patient Signature or Legal Guardian Date

6 NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLY. Central Coast Behavioral Health INC is committed to protecting medical information about you. This Notice tells you about the ways in which Central Coast Behavioral Health INC. or an authorized assistant, may use and disclose medical information about you. Central Coast Behavioral Health INC is required by law to make sure your medical information is protected and provide you with this Notice about your rights and our legal duties and privacy practices with respect to your medical information. How Central Coast Behavioral Health INC May Use and Disclose Your Medical Information Central Coast Behavioral Health INC may use and disclose your medical information for different purposes. Some information, such as certain drug and alcohol information, HIV information and mental health information, is restricted in its use and disclosure. Central Coast Behavioral Health INC abides by all applicable state and federal laws related to the protection of this information. The examples below are provided to illustrate the types of uses and disclosures Central Coast Behavioral Health INC may make without your authorization. Treatment. Central Coast Behavioral Health INC may use and disclose your medical information to assist your health care providers (doctors, dentists, pharmacies, hospitals and others) in your diagnosis and treatment. For example, if you are referred to another provider, that provider will need to know if you are allergic to any medications. Payment. If necessary Central Coast Behavioral Health INC may use and disclose your medical information so that he may bill and collect for treatment and services you received. For example, your medical information may be used to process claims and collect payment. Appointment Reminders. Central Coast Behavioral Health INC may contact you to remind you that you have an appointment. Treatment Alternatives. Central Coast Behavioral Health INC may tell you about or recommend possible treatment options or alternatives that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care. Central Coast Behavioral Health INC may release medical information about you to a relative, close personal friend or any other person you identify if that person is involved in your care and the information is relevant to your care. If the patient is a minor, Central Coast Behavioral Health INC may disclose information to a parent or guardian when permitted by law. As Required by Law. Central Coast Behavioral Health INC will disclose medical information about you when required to do so by law. Public Health Activities. Central Coast Behavioral Health INC may disclose medical information to public health agencies for reasons such as preventing or controlling disease, injury or disability. Victims of Abuse, Neglect or Domestic Violence. Central Coast Behavioral Health INC may disclose medical information to government agencies about abuse, neglect or domestic violence. Health Oversight Activities. Central Coast Behavioral Health INC may disclose medical information to governmental, licensing, auditing and accrediting agencies as authorized or required by law.

7 Judicial and Administrative Proceedings. Central Coast Behavioral Health INC may disclose medical information in response to a court or administrative order. Central Coast Behavioral Health INC may also disclose medical information about you in certain cases in response to subpoena, discovery request or other lawful process. Law Enforcement. Central Coast Behavioral Health INC may disclose medical information under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime. Coroners, Funeral Directors, Organ Donation. Central Coast Behavioral Health INC may release medical information to coroners or funeral directors as necessary to allow them to carry out their duties. To Avert a Serious Threat to Health or Safety. Central Coast Behavioral Health INC may disclose medical information about you, with some limitations, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. National Security and Intelligence Activities. As authorized or required by law, Central Coast Behavioral Health INC may disclose medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities. This may include special investigations or providing protection to the president, other authorized persons or foreign heads of state. Workers Compensation. Central Coast Behavioral Health INC may disclose medical information to the extent necessary to comply with California law for workers compensation programs. Inmates. If you are an inmate of a correctional institution or under the custody of law enforcement officials, Central Coast Behavioral Health INC may release medical information about you to the correctional institution as authorized or required by law. Other Uses or Disclosures with an Authorization. Other uses or disclosures of your medical information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke (or cancel) an authorization at any time in writing. If you cancel your authorization in writing, Central Coast Behavioral Health INC will not disclose medical information about you after we receive your cancellation, except for disclosures which were being processed before Central Coast Behavioral Health INC received your cancellation. Your Rights Regarding Your Medical Information. You have certain rights regarding your medical health information that Central Coast Behavioral Health INC maintain about you. For the following rights, your request must be made in writing. Right to Access to See and Copy Your Medical Information. You have the right to review or obtain copies of your medical information records, with some limited exceptions. Right to Amend Your Medical Information. If you feel that medical information that Central Coast Behavioral Health INC may have about you is incorrect or incomplete, you may request that Central Coast Behavioral Health INC amend (correct or supplement) the information. Your request must include the reason you are seeking a change. Central Coast Behavioral Health INC may deny your request if you ask to amend information that was not created by Central Coast Behavioral Health INC, is not part of the medical information kept by Central Coast Behavioral Health INC, is not part of the medical information you would be allowed to see and copy, or you ask to amend a record that is already accurate and complete. If Central Coast Behavioral Health INC denies your request to amend, he will notify you in writing. You then have a right to submit a written statement of disagreement with his decision.

8 Right to an Accounting of Disclosures. You have the right to request an accounting or list of disclosures Central Coast Behavioral Health INC have made of your medical information. Right to Request Restrictions on the Use and Disclosure of Your Medical Information. You have the right to request that Central Coast Behavioral Health INC restrict or limit how he use or disclose your medical information for treatment, payment or health care operations. He may not agree to your request. If he do agree, he will comply with your request unless the information is needed for an emergency. In your request, you must tell him (1) what information you want to limit; (2) whether you want to limit how he use or disclose your information, or both; and (3) to whom you want the restrictions to apply. Right to Request Confidential Communications. You have the right to request that Central Coast Behavioral Health INC communicate with you about medical matters in a certain way or at a certain location. For example, you may request that he contact you at work rather than home. Your request must specify how or where you wish to be contacted. He will accommodate all reasonable requests. Right to a Paper Copy of This Notice. You have a right to a paper copy of this Notice and you may ask Central Coast Behavioral Health INC to give you a copy of this Notice at any time. Changes to This Notice. Central Coast Behavioral Health INC reserve the right to change the terms of this Notice at any time, effective for medical information that he already have about you as well as any information that he receive in the future. You may always request a copy of the current Notice in effect. This notice is in effect as of August 1, Complaints. If you believe that your privacy rights have been violated or you want to complain about Central Coast Behavioral Health INC privacy practices, you may file a complaint with The US Department of Health and Human Services, 200 Independence Ave., Washington, D.C Please allow the individuals listed below to have access to my medical records: Name Relationship By signing this form, you consent Central Coast Behavioral Health, Inc. to use or disclose your protected health information as outlined above. Patient Name: Patient Signature: Date of Birth: Date:

9 CONSENT FOR eprescribe PROGRAM eprescribing is way for doctors to send electronically an accurate, error free, and understandable prescription from the doctor s office to the pharmacy. The eprescribe Program also includes: Formulary and benefit transactions - Gives the health care provider information about which drugs are covered by your drug benefit plan. Fill status notification - Allows the health care provider to receive an electronic notice from the pharmacy telling them if your prescription has been picked up, not picked up, or partially filled. Medication history transactions - Provides the health care provider with information about your current and past prescriptions. This allows health care providers to be better informed about potential medication issues and to use that information to improve safety and quality. Medication history data can indicate: compliance with prescribed regimens; therapeutic interventions; drug-drug and drug-allergy interactions; adverse drug reactions; and duplicative therapy. The medication history information would include medications prescribed by your health care provider at Central Coast Behavioral Health INC as well as other health care providers involved in your care and may include sensitive information including, but not limited to, medications related to mental health conditions, venereal diseases/sexually transmitted diseases, abortion(s), rape/sexual assault, substance (drug and alcohol) abuse, genetic diseases, and HIV/AIDS. As part of this Consent Form, you specifically consent to the release of this and other sensitive health information. Consent By signing this consent form you are agreeing that your provider at Central Coast Behavioral Health, Inc. may request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payers for treatment purposes. You may decide not to sign this form. Your choice will not affect your ability to get medical care, payment for your medical care, or your medical care benefits. Your choice to give or to deny consent may not be the basis for denial of health services. You also have a right to receive a copy of this form after you have signed it. This consent form will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing but if you do, it will not have an effect on any actions taken prior to receiving the revocation. Understanding all of the above, I hereby provide informed consent to Central Coast Behavioral Health, Inc. to enroll me in this eprescribe Program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction. Patient Name: Patient Signature: Date of Birth: Date:

10 OFFICE POLICIES & PROCEDURES The following describes the Office Policies and Procedures for Central Coast Behavioral Health, Inc. These are designed to provide optimal care for your psychiatric needs. Our Office: Welcome to Central Coast Behavioral Health, Inc. We are a corporation intended to enhance ones mental health and wellness. We do this by working as a team consisting of Dr. Pedro Guimaraes (psychiatrist), Dr. Elizabeth Ganiron (psychologist), Mary Meiselman, NP, Bianca Iglesias, PA-C, Lisa Ratterree, LVN, and Amanda Selman, RN. Besides our clinicians, we have a highly trained administrative staff that will handle anything you may need. Our model uses our nurse practitioner, physician s assistant, and registered nurses as the first point of contact with Dr. Guimaraes overseeing all the patients and their treatment plans. While you may not see Dr. Guimaraes in every appointment, be assured that he closely follows and discusses your care with the health care professionals you see on a regular basis. You may always ask for Dr. Guimaraes to accompany your health care professional during your appointment. Office Hours & Telephone Calls: Our office is open Monday- Thursday from 8:45 am to 5:00 pm. We are closed daily for lunch from 12:15 pm- 1:15 pm. If you reach us outside of normal business hours, you may leave a voic on our office telephone (805) We are closed every Friday and major holidays including: New Year s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Christmas Eve, Christmas Day, and New Year s Eve. If you are experiencing a true medical emergency, please call 911 immediately. If you are in crisis and need to reach us outside of regular office hours, please call (805) The answering service will contact the doctor and a qualified staff member will return your call within one hour. Evaluations: Your treatment with Central Coast Behavioral Health, Inc. begins with a Psychiatric Evaluation that will be 60 minutes in length. The goal of the Evaluation is to determine your specific Psychiatric needs and develop a treatment plan. While this plan generally leads to continued treatment in the practice, there are some cases when it would be beneficial for a patient to receive care in another setting. Treatment plans will be discussed at the end of the Psychiatric Evaluation. Check-In Procedure & Payment: You are required to check-in at the start of each appointment. We ask that you arrive 10 minutes early to complete the DSM-5 Symptom Measure before each appointment. This will help us determine how you have been doing since your last appointment. All fees (i.e. co-pay, co-insurance, self-pay fee) are due prior to the appointment. Insurance: Central Coast Behavioral Health, Inc. maintains contracts with several Insurance Providers. You authorize the office of Central Coast Behavioral Health, Inc. and Billing Agency to release any necessary information to your insurance carrier for claim submission and/or continued care. You authorize payment for services rendered to be sent directly to Dr. Pedro Guimaraes for any benefits available under your insurance plan. You understand that it is your responsibility to notify Central Coast Behavioral Health, Inc. of any insurance change. You understand that you are financially responsible for any coinsurance amount (deductible, co-pay, etc.) and any balance (patient responsibility, self-pay, etc.) for services rendered. You authorize Central Coast Behavioral Health, Inc. to retain your signature on file for the purpose of claim submission. You hereby agree to these terms and conditions, the no show/cancelation policy and consent for treatment. Late Arrival to Appointments, No-Show Policy, 24 Hours Cancellation Policy: It is your responsibility to be on time for your appointment. If you are 10 minutes or more late to your appointment, you will not be seen. The appointment times are reserved for each patient. We require a 24 hour advanced cancellation of all scheduled appointments. If you call outside of office hours, you may leave a message on our office line (805) These messages are checked first

11 thing every morning and multiple times throughout the day. If we do not receive a notice of cancellation and you No- Show to your appointment, you will be charged a No-Show fee of $115. Insurance companies do not pay for appointments missed, therefore, you will be responsible for the entire No-Show fee. Adherence to this policy is necessary for optimal care of all patients. The policy assumes a high level of commitment from our patients and is necessary to provide fair and effective treatment for all patients. Medication Refills: It is your responsibility to contact your pharmacy for all prescription refills at least 3-5 days in advance. Refills will be sent within 48 business hours upon receiving the pharmacy s request. For all controlled medications, you are required to be seen on a monthly basis until otherwise specified by the clinician. For all other medications, you are required to come in at least once every three months to receive refills. If you are not seen within three months, your prescription will not be refilled until you are seen for an appointment. Please see the following rules that apply when taking medications prescribed by Central Coast Behavioral Health, Inc. A) I will not share this/these medication(s), nor use previously prescribed medication or others medication. B) I understand lost or stolen medications or prescriptions will not be replaced. C) I understand that early refill requests will be denied and may be considered a violation of this agreement. D) I understand that medication refills must be submitted at least 72 hours in advance. E) I understand that medications prescribed by Central Coast Behavioral Health, Inc. may not be duplicated by another doctor/office. F) I understand that disruptive behavior or threats (or the appearance of this) toward staff and/or other patients will not be tolerated and will result in termination of care from Central Coast Behavioral Health, Inc. Disruptive behavior can include excessive phone calling. Coordination of Care: As a Psychiatrist, we work closely with primary care doctors, referring physicians and therapists. We ask that you fill out the information below so we can coordinate care with your other doctors. If you do not want us to release any information regarding your psychiatric care, please check the box below. I authorize the release of my psychiatric records to my primary care doctor and therapist. I do not authorize the release of my psychiatric records to my primary care doctor and therapist. Primary Care Doctor (First & Last Name) Primary Care Doctor s Phone Number Psychologist/Therapist (First & Last Name) Psychologist/Therapist Phone Number I hereby authorize that I have read and understand all of the above listed policies and procedures for Central Coast Behavioral Health, Inc. Patient Name (Printed) Patient Signature Date