Forms, Information, Resources

Please click on the links below to download forms and resources.

Self-Care Guide – a thin book to help you through a rough patch in life:

Self-Care Guide

https://orchardhumanservices.org/wp-content/uploads/2020/03/Telemental-Health-Form-for-Orchard-Human-Services.pdf

Forms for care of a child or minor:

Child-Intake-Form

HIPAA Privacy Form

Telemental Health Permission Form

If you have insurance or any other party is paying for your care, please complete the Consent for Third Party Billing form.

If you want us to discuss your child’s care with another adult, please complete the Authorization to Provide Treatment to a Minor. For example, if you are the parent who has legal authority to make decisions on behalf of your child, please complete this form if you want us to also discuss your child’s case with your co-parent, partner, grandparent, or other adult.

If custody of the child has been ordered by a court, please also submit a COPY of the Court Ordered Custody Agreement with Parenting Plan so we know we have the appropriate permission to provide services to your child.

Forms for care of an adult

Adult-Intake-Form

HIPAA Privacy Form

Telemental Health Permission Form

If you have insurance or any other party is paying for your care, please complete the Consent for Third Party Billing form.

No-Harm Contract – for information only

No-Harm-Contract

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