Need help accessing forms? Contact our staff for assistance – call (770) 686-0894 or email Forms@OrchardHumanServices.org
ONLINE FILLABLE FORMS FOR MINOR CHILD – UNDER 18
New Minor Child Multi-Part Quick Form
AFTER COMPLETING ABOVE 2 FORMS, PLEASE SUBMIT FOLLOWING DOCUMENTATION:
Please submit a copy of identification, insurance card (if unable to upload in the form), Court Parenting Plan if applicable, and any relevant mental health, medical, or educational records (i.e. IEP, Section 504 Plan, FBA/BIP, Neuropsychological or Psychological Evaluation, Test Scores, Report Card) to support care to one of the following:
- Email Forms@orchardhumanservices.org
- Secure Fax (877) 660-8884
- Text 770-686-0894
NEXT – If you are self-paying for care (not using insurance), please complete the 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
AUTHORIZATION FOR TREATMENT OF A MINOR
If you are the legal parent/guardian [by law or as appointed by a Judge under a Parenting Plan from Custody Agreement] and wish to provide permission for another adult to participate in your child’s care (such as a step-parent, grandparent, etc.), please complete the following form:
Authorization for Treatment of Minor
AUTHORIZATION & RELEASE FORM
To authorize Orchard Human Services, Inc. staff to share information with a doctor, provider, or other individual, please complete this form with signature and date. Click here to complete form.
FERPA RELEASE FORM
To authorize Orchard Human Services, Inc. staff to speak with your school, college, technical school, or university. Click here to complete form.
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]
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.
Fees are discussed on the counseling page; or ask staff for more information.
