Endurancebehavioralhealth.com

Endurance Behavioral Health

WEBEndurance Behavioral Health is a mental health partial-hospitalization program (PHP) for adolescents ages 13-20, located in the Seacoast Region of New Hampshire. Our …

Actived: 8 days ago

URL: https://endurancebehavioralhealth.com/

INTAKE REQUEST FORM

WEBINTAKE REQUEST FORM Dat e of Request : _____/ _____/ _____ Cl i en t’s Name: _____ Cl i en t’s Date o f Bi rth _____/ _____/ _____ Ag e: ____ S ex: __mal e

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Intake Request Form 2024 Update

WEBENDURANCE BEHAVIORAL HEALTH INTAKE REQUEST FORM. Please have a parent/guardian call us after sending in this form, to start the intake process. Call (603) …

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MENTAL HEALTH BILL OF RIGHTS

WEBf. significant threats to self, others or property. (4) To a safe setting and to know that the services provided are effective and of a quality consistent with the standard of care …

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CONSENTFORTREATMENTANDAUTHORIZATIONTOBILLINSURANCE

WEBCONSENT FOR TREATMENT AND AUTHORIZATION TO BILL INSURANCE. Please read and initial each item below, then sign at the bottom. __________I certify that I am …

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AUTHORIZATIONFORDISCLOSUREOFPROTECTEDHEALTHINFORMATION …

WEBTitle: Microsoft Word - EBH AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION.docx Author: cdesrosiers Created Date: 4/22/2014 7:33:46 PM

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NOTICETOCLIENTSANDCONSENTTOTREATMENTAGREEMENT …

WEBNOTICETOCLIENTSANDCONSENTTOTREATMENTAGREEMENT! TOOURCLIENTS:!TheBoardofMentalHealthPracticeregulations,includingtheMentalHealthBillof …

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E NDURANCE BE HAV I O RAL HE ALT H I NTAKE RE Q UE S T …

WEBENDURANCE BEHAVIORAL HEALTH INTAKE REQUEST FORM. Parent/Guardian must call after this form is sent in to start the intake process. Call (603) 760-1942 x309. …

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Sean, Author at Endurance Behavioral Health

WEBLorem ipsum dolor sit amet, consectetur adipisicing elit. Illas patet doceat motu plus honeste percussit summo andriam simul. Graecis accommodare fortitudinis …

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P l e a s e F a x to 6 0 3 -7 6 0 -1 9 4 9

WEBCurrently Hospitalized? YES NO If Yes, Where?_____ Discharge Date: :____/_____/_____ Eval or discharge forms faxed to us?

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ADOLESCENT HEALTH HISTORY

WEBHealth History 2 2 What psychiatric diagnoses (if any) does your child have? DIAGNOSIS DATE ESTABLISHED BY WHOM? Current Medications List all psychiatric, non …

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