Patient's Name *

First Name Last Name

Date of Birth *

Patient's Age *

Nickname or Alias

Patient's Social Security Number *

Patient's Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Home/Evening Phone Number *

Area Code Phone Number

Cell Phone Number *

Area Code Phone Number

Name of Legal Guardian *

Billing Information:

Insurance: *

Medicaid Number: *

Please read and agree to the following:

I agree to allow Mosaic Psychological Services, LLC to contact my primary care physician or mental health counselor and/or treating psychiatrist for medical records or to release information. *

Type I Agree above

I agree that if you or your child have been referred for a psychological evaluation by DFCS, DJJ, Court Order, Behavioral Health Services, or any other agency, the referring agency will be the official owner of the report that will be provided. This is called a "third party" report or evaluation and does NOT fall under the HIPAA rules. If you wish to have a copy of the report, you must ask the referring agency. Mosaic Psychological Services, LLC is not allowed to provide you with a copy. *

Type I Agree above

I agree that if you or your child are court ordered to have a psychological evaluation, you have the right not to answer any question, but your refusal will be included in the report which is provided to the Judge or agency that requested the evaluation. *

Type I Agree above

I understand I may not agree with the clinical findings of the report. *

Type I Agree above

If you or your child is being seen for therapy by a clinician at Mosaic Psychological Services, LLC, clinical/treatment notes are maintained by your clinician. Progress notes will not be released except under rare circumstances. *

Type I Agree above

I understand that a typed version of my name may be accepted as my original signature pursuant to the Georgia Uniform Electronic Transactions Act (O.C.G.A. 10-12-7). To accept the above statement, type "I Understand" in the box below. *

Print Name of Guardian or Representative *

Date

Relationship to Client *

Signature of Guardian or Representative *

In order for the submission to be accepted, you must use your mouse and draw your signature above. Clear

Child DFCS Information Form