Patient Orientation Checklist
Orientation Checklist for OMHC (Outpatient Mental Health Clinic) Patients
Welcome to our Outpatient Mental Health Clinic (OMHC)! We are delighted to have you as a new patient.
This orientation checklist will help familiarize you with our clinic's processes and resources to ensure you
have a smooth and comfortable experience. Please check off each item as you complete it:
1. Registration and Intake:
- Complete all necessary registration forms.
- Provide accurate and up-to-date contact information.
- Inform us of any allergies or medical conditions that may be relevant to your treatment.
2. Insurance and Payment:
- Verify your insurance coverage and understand your benefits.
- Discuss any financial concerns or payment options with our staff.
3. Scheduling and Appointments:
- Schedule your initial appointment and subsequent follow-ups as needed.
- Make a note of your appointment date, time, and location.
- Set up reminders for appointments to help you remember.
4. Clinic Policies and Procedures:
- Review and acknowledge our clinic's policies and procedures.
- Understand the cancellation and rescheduling policy.
- Familiarize yourself with our confidentiality and privacy practices.
5. Clinic Tour:
- Take a tour of our clinic to locate key areas, such as waiting rooms, restrooms, and counseling rooms.
- Meet the reception staff and get acquainted with their names and roles.
6. Treatment Plan:
- Discuss your treatment goals with your assigned mental health provider.
- Collaborate on developing a personalized treatment plan.
- Understand the frequency and duration of your counseling sessions.
7. Emergency Contact Information:
- Provide emergency contact details to keep on record.
- Learn how to access crisis intervention services during non-business hours.
8. Medication Management (if applicable):
- If prescribed medication, understand the dosage, frequency, and potential side effects.
- Clarify any questions you have about your medication.
9. Resources and Support Services:
- Learn about additional resources and support services offered by the clinic.
- Ask about support groups or workshops that may be relevant to your needs.
10. Communication Preferences:
- Inform the clinic staff about your preferred mode of communication (phone, email, etc.).
- Specify any communication restrictions or preferences related to your privacy.
11. Feedback and Concerns:
- Know how to provide feedback or voice any concerns about your experience.
- Understand the process for addressing complaints or suggestions.
12. Follow-up:
- Schedule any necessary follow-up appointments.
- Make a note of important contact numbers and addresses.
Remember, our team is here to support you on your journey to improved mental health. If you have any
questions or need assistance, feel free to ask. We wish you the best in your treatment and well-being.
Alex Wilson Husson
Name: ____ ____________________
Signature: _______________________________________
Telehealth Services Informed Consent
Name:___Alex Husson __________
05/08/1990
Date of Birth: _____________________
Definition of Telehealth
Telehealth involves the use of electronic communications to enable professionals to connect with
individuals using interactive video and audio communications. Telehealth includes the practice of
psychological health care delivery, diagnosis, consultation, treatment, referral to resources,
education, and the transfer of medical and clinical data.
I understand that I have the rights with respect to telehealth:
1. I understand privacy and the confidentiality laws apply to telehealth, and that no information
obtained through the use of telehealth services will be disclosed to researchers or other
entities without my written consent.
2. My health care provider has explained how the videoconferencing technology will be used to
conduct a telehealth session, that unlike a direct patient/provider in person, I will not be in the
same room as my health care provider.
3. I understand the potential risks to technology including interruptions, unauthorized access
and technical difficulties. I understand my health care provider or I can discontinue the
videoconference consult/visit if it is believed videoconferencing technologies are not
adequate for the situation.
4. I understand that I have the right to withhold or withdraw my consent to the use of telehealth
in the course of my care at any time, without affecting my right to future care or treatment.
5. I understand that telehealth may involve electronic communication of my personal medical
information to other medical practitioners who may be located in other areas, including out of
state.
6. I understand that no results for anticipated benefits can be guaranteed or assured by my
provider.
7. I understand my healthcare information may be shared with other individuals for purposes of
scheduling and billing. Individuals others than my healthcare provider may be present during
the session in order to operate videoconferencing equipment. I further understand that I will
be informed of their presence, and that such individuals will maintain confidentiality on
information obtained during the session. Furthermore, I have the right to request the
following:
○ ask non-medical personnel to leave the telehealth examination room; and/or
○ terminate the consultation at any time.
8. I agree certain situations, such as emergencies and crisis, are inappropriate for
audio/video/computer-based psychotherapy services. If I am in crisis or in an emergency, I
should immediately call 911 or seek help from a hospital or crisis-oriented healthcare facility
in my immediate area.
Consent to The Use of Telehealth
By signing this form, I certify:
● That I have read or had this form read and/or had this form explained to me.
● That I fully understand its contents including the risks and benefits of the procedure(s).
● That I have been given ample opportunity to ask questions and that any questions have
been answered to my satisfaction.
Client Signature: ___________________________
Guardian Name: ____________________________
Guardian Signature:_________________________
Records Release Authorization
FOR THE RELEASE OF PROTECTED MENTAL HEALTH
INFORMATION
By signing this form, confidential psychological and psychiatric information can be released to
and/or discussed with the people or agencies listed below unless noted by exclusions or
limitations. This form is signed voluntarily and may be revoked at any time. All disclosures made
pursuant to this form are valid as long as they were made before the date of revocation.
Patient Name____ Alex Husson _________
05/08/1990
Patient Date of Birth: ____________________
I authorize my provider to:
RELEASE psychological/psychiatric mental health information to/from the SECOND
PARTY as directed below.
RECEIVE psychological/psychiatric mental health information to/from the SECOND
PARTY as directed below:
Second Party
Ms.Johnson, Howard County Office of Probation
Name:________________________________________________________________________
3451 Court House Dr., Ellicott City, MD, 21043
Address: ______________________________________________________________________
(410)480-7700
Fax Number: __________________________
Phone Number: ________________________
(443)379-9564
Type of Information to be Disclosed
I authorize disclosure of all health information, including information relating to medical,
pharmacy, mental health, substance abuse, and psychotherapy
I authorize only the disclosure of the following information:
Purpose of Disclosure
My health information is being disclosed at my request or at the request of my personal
representative; or
My health information is being disclosed for the following purpose:
Note any exclusions or limitations here:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
I understand that treatment, payment, enrollment in a health plan, or eligibility for benefits is not
dependent on my signing this authorization. By signing below, I acknowledge that I have read
and understand this document and that I have voluntarily given my provider authorization to
disclose my records. I understand that I may revoke this authorization at any time by providing a
written notice to my provider, however the revocation will not have an effect on any actions
taken prior to the date my revocation is received. I understand that my information may be
redisclosed by the authorized person/organization receiving the information, and at that point,
the information may no longer be protected under the terms of this agreement. This
authorization will expire one year following the date signed unless revoked in writing.
Alex Husson
Signature:_____________________________
Authorization is given on this patient’s behalf due to being a minor or unable to sign
Legal Guardian/Personal Representative Signature: _____________________________________
Client Safety Contract
ARISE HEALTH CLINIC.
10705 Charter Drive Suite 430
Columbia, MD 21044
Phone: (301) 259-3574
E-mail: info@arisehealthclinic.com Website: www.arisehealthclinic.com
Client Safety Contract
By Signing this form, I (client), herby contract with Arise Health Clinic/Mental Health
Provider, that I will take the following actions if I feel suicidal.
1. I WILL NOT ATTEMPT SUICIDE
2. I will go to the nearest Emergency Department if I feel suicidal.
3. If I do not reach my assigned provider, I will phone any of the following services:
Name/Agency:
http://www.aamentalhealth.org/pr_warmline. 410-768-5522
National Suicide Prevention Hotlines 1-800-SUICIDE(784-2433) or 1-800-273-
TALK (8255)
Disaster Distress (Helpline offers Immediate Crisis Counseling)
1800-985-5990 or text “TalkWithUs” to 66746
1800-985-5990 or text “Hablanos” to 66746 (Spanish)
4. I will further seek support from any of the following people: (List the name of people on
the box below)
5. If none of these actions are helpful or not available, I will go to the nearest ER
6. If I am unable to get help or am unable to go to the hospital, I will call 911 and request
help.
I agree to use electronic records and signatures and I acknowledge that I have read the
related consumer disclosure.
Alex Husson 2/28/2024
Name: ___ ________________ Date: _________________
Signature: _____________________________
Guardians Name:_____________________________ Date: __________________
Guardian’s Signature: _________________________
Credit Card Authorization Form
The undersigned agrees and authorizes Arise Health Clinic to save the credit card(s) indicated below on
file. The use of this form is optional and for your convenience.
Card Number Ending: ___________________________
Expiration Date: _______________________________
Billing Address: ________________________________
I authorize Arise Health Clinic to process above credit card as "Card on File" and charge in
accordance with the agreed upon payment plan between the practice and me (e.g. one time
charge, monthly payment plan, etc). I understand this authorization will remain in effect until the
expiration of the credit card account. Patient may also revoke this form by submitting a written
request to the medical practice.
I agree to use electronic records and signatures and I acknowledge that I have read the related consumer
disclosure.
Name:______ ________________
Signature: _________________________________
Date: _____________________________________
Alex Husson
2/28/2024
Alex Husson
Alex Wilson Husson
2/28/2024
Alex Wilson Husson
2/28/2024
