Instructions for New Patients
New Patient Intake Forms:

Fees and Services Agreement (MS WORD)
North Carolina Notice (MS WORD)
Health & Treatment History Form (MS WORD)
Intake Form

UBH Members (required for all adults and children at the first visit):

ALERT Wellness Assessment (adults)
ALERT Wellness Assessment (child/teen)

Optional Forms:

Consent for Exchange of Patient Information (MS WORD)
Consent For Release of Patient Information (MS WORD)
Consent for Exchange of Information in Case of Emergency

Instructions for New Patients
You can save time filling out forms during your first office visit by printing and filling out the documents listed under "New patient Intake Forms" above. Please fill out the Health and Treatment History Form, and the Intake Form. The "North Carolina Notice" and the "Fees and Services Agreement" are important informational documents for your own use, and are for you to keep. However, your therapist will be discussing the documents with you during your first visit, and will be happy to answer any questions you have at that time. Please print out the "Signature Page" (the last page) of the Fees and Services Agreement and bring it with you to the first visit as well. The three optional forms, the Consent Forms, are to be filled out only if you wish for your therapist to communicate with another care provider or professional, such as your medical doctor, prior therapist, or psychiatrist.

UBH (United Behavioral Health) members, please note that the ALERT Wellness Assessment form is required by your insurance company on the first visit. Please fill it out either for yourself or for your child, and bring it with you to your first appointment. UBH also requires that you complete a second ALERT form between visits 3 and 5, but they send a pre-populated form to our office after they receive your first ALERT form. GMH will fax your first form to UBH for you.

We will gladly discuss fees prior to making an initial appointment and provide a detailed fees policy before your first session. As an added service to you, we accept and will file for most insurance plans and are members of many managed care provider plans. We do our best to handle insurance benefits, claims, and billing issues in a timely and accurate fashion. However, insurance policies have become increasingly complex as have errors on the part of insurance companies themselves. As a result of the complexity involved in filing insurance for you, we would like to remind you of the following:

1.) While we check your benefits for you as a courtesy, it is ultimately your responsibility to be informed, stay informed, and communicate with us about your insurance benefits. We recommend that you call your insurance company yourself before your first visit and check your mental health benefits.

2.) Your benefits are not guaranteed until claims are filed on your behalf and your insurance pays on those claims. It typically takes four to six weeks after your first session at GMH before your insurance pays on the claims and sends us a final explanation of your benefits.

3.) We are only as accurate as the information your insurance company gives us. Occasionally, insurance companies gives us inaccurate information about co-pays, deductibles, session limits, etc. We are required to charge you what they tell us to charge you. If you believe there has been an error in your benefits, it is your responsibility to address the problem with your insurance company and to pay your GMH bill in a timely fashion. GMH is not financially responsible in the event of a disagreement between what you thought your insurance would pay and what they end up paying.

4.) While we do our best to keep track of session limits, it is also your responsibility to be aware of how many sessions you insurance company allows per year, and to keep track of how many sessions you are using at GMH and with other mental health providers such as psychiatrists. Your GMH therapist has no way of knowing how many sessions per year you have used with other mental health providers, and thus, it is ultimately your responsibility to be aware of when you have used up all your sessions for the year.