Request edit access
Intake Form - A-1 Behavioral Health Services  

Providers: Joy Ichie MSN, APRN, PMHNP-BC, DNP | Azeza Uddin, MD (Collaborating Psychiatrist)

Office Locations

  • New Hampshire: 25 Nashua Rd Unit A-1, Londonderry, NH 03053 | Tel 1-800-609-0323

  • Oregon: 609 E Main St, Cottage Grove, OR 97424 | Tel 541-945-3305

  • Arizona: 2760 W Peoria Ave #1204, Phoenix, AZ 85029 | Tel 1-800-609-0323

  • New York: Tree of Life Counseling, 95 Allens Creek Rd Bld 1 #200, Rochester, NY 14618 | Tel 1-800-609-0323

  • Texas (Main Office): 3740 N Josey Ln #213, Carrollton, TX 75007 | Tel 972-656-8258

Practice Policies, Procedures and Patient Treatment Agreement

(All text from your original file included; section covers office hours, communication, insurance, payments, appointments, labs, refills, prior authorization, court policy, medical records, forms policy, medication management, scope of practice, conduct, termination, confidentiality, and policy acceptance.)

Treatment Consent

Acknowledges understanding of evaluation, risks, benefits, and voluntary consent to treatment. Includes signature/date lines.

Notice of Privacy Practices

Full HIPAA notice describing how A-1 Behavioral Health Services may use/disclose protected health information, patient rights, and contact information for complaints.

Sign in to Google to save your progress. Learn more
Email *
Date *
MM
/
DD
/
YYYY
Title (Check one): *
Required
Address:   *
City *
State *
ZIP *
Home Phone *
Work Phone *
Cell Phone *
Date of Birth: *
MM
/
DD
/
YYYY
Date of Birth: *
MM
/
DD
/
YYYY
Sex: *
Required
Social Security #: *
Marital Status:   *
Required
Height: *
Weight *
Employment Status: *
Education Completed: *
Spouse Data *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms