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.
Need help accessing the forms? Call or email our staff for assistance at (770) 686-0894 or Appointments @Orchard Human Services.org
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.

Section A) Self-Care Guide –

a thin book to help you through

a rough patch in life:

 

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Click on link to download free E-book: Self-Care Guide

Please click on the links below to download forms or complete online fillable forms: 

 

Section B) FORMS for care of a child or minor:

You have 3 choices for submitting information for new client appointments.

  1.  Online Quick Form – Fillable Multi-Part Form
  2.  Online Individual Fillable Forms
  3.  Individual PDF Downloadable Forms to Complete on Paper 

Online Quick Form – to make it easier for parents to complete online information in one seamless process. If you choose this option, you may have to upload or submit additional information separately:

New Minor Child Multi-Part Quick Form

Appointment Policy

Online Individual Forms – You can complete each online form, one at a time, to allow for more comprehensive information. You may have to upload or submit additional information separately:

Individual PDF Downloadable Forms – Download each individual form, print on paper, fill out by hand, and fax or scan back. Email forms and documents back to Forms@OrchardHumanServices.org or fax to 877-660-8884.

  • Downloadable PDF Child-Intake-Form
  • Downloadable PDF HIPAA Privacy Form
  • Downloadable PDF Telemental Health Permission Form
  • Downloadable PDF Consent for Third Party Billing … If you have insurance or any other party is paying for your care, please complete the form.
  • Downloadable PDF Authorization to Provide Treatment to a Minor … Please complete if you want us to discuss your child’s care with another adult, or have another adult access or participate in services for your minor child. 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.

Section C) FORMS for care of an adult:

You have two options for completing new client form for adults.

  1. Online Fillable Forms – fill out online, sign, submit
  2. Downloadable PDF Forms – print, fill out by hand, and fax or scan back

ONLINE FILLABLE FORMS FOR ADULTS

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

DOWNLOADABLE PDF FORMS 

Section D) 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.

Section E) 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.

 

Section F) Safety Planning – for information only

Safety Plan

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

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