Forms – Adult

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Need help accessing forms? Contact our staff for assistance – call (770) 686-0894 or email Forms@OrchardHuman Services.org

ONLINE FILLABLE FORMS FOR ADULT – 18+

Online Fillable Adult New Client Form

Individual Online Fillable HIPAA Privacy Form

Individual Online Fillable Telemental Health Permission Form

Individual Online Fillable Consent for Third Party Billing

Individual Online Fillable Appointment Policy  

Please submit a copy of identification, insurance card (if unable to upload in the form), and any relevant mental health, medical, or educational records to support care to one of the following:

  1. Email Forms@orchardhumanservices.org
  2. Secure Fax (877) 660-8884
  3. Text 770-686-0894

NEXT – If you are self-paying for care (no insurance), please complete No Surprise Act forms

No Surprise Act Notice

You have rights as a client; this organization complies with the 2022 No-Surprise Act to the extent allowed by law and ethical standards of practice. Please see forms below and feel free to ask our staff about this new law.  Fees are discussed on the counseling page; or ask staff for more information.
1. Click here to complete the REQUIRED No Surprise Act Standard Notice & Consent Documents.
2. You can download a No-surprise Act Disclosure Statement here; download and print or email to yourself.
3. Click here to download a blank copy of the entire set of No Surprise Act Standard Notice & Consent Documents.

ADDITIONAL SPECIAL FORMS

IF YOU ARE GUARDIAN OF AN ADULT OR AN ADULT WHO IS AUTHORIZING ANOTHER PERSON(S) TO BE INVOLVED IN YOUR CARE:

Adult Authorization Form

ASSESSMENT FORMS

Click Here To Complete PCL-5 Assessment Form – Then print and email results to drdarleen@orchardhumanservices.org or fax to 877-660-8884

SAFETY PLAN

Click Here To Access Safety Planning Form

Crisis Support Resources

Want to receive a text-back with crisis resources? Then call (888) 263-1986 and our system will automatically send you a text with crisis resources, referrals, and other valuable information. Your information is confidential; we only respond to your request for resources.

State Crisis Resources:

  • Florida Mental Health Hotline at 866-903-3787
  • Georgia Crisis & Access Line 1-800-715-4225
  • Virginia Mental Health Hotline at 866-903-3787

National Crisis Resources:

  • National Crisis Support Text “HELLO” to 741741
  • National Crisis Hotline 1-800-273-8255
  • Call 988 (National Suicide Crisis Line)
  • Call 911 (Call for Emergency Response) 
  • Go To Local Emergency Room

Orchard’s Crisis Resources:

  • Download “Self-Care Guide” from Orchard’s website:

https://orchardhumanservices.org/wp-content/uploads/2019/04/Self-Care-Guide.pdf

  • Contact Orchard Human Services – we offer limited crisis support services:

Text or call (770) 686-0894 [Must Call If After Hours; We Do Not Monitor Texts After Hours]

Fees are discussed on the counseling page; or ask staff for more information.

Want to receive a text-back with crisis resources? Then call (888) 263-1986 and our system will automatically send you a text with crisis resources, referrals, and other valuable information. Your information is confidential; we only respond to your request for resources.

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