NHTC OP Registration Form

Section IV: Demographics
Gender:
Veteran's Status:
Race:
Ethnicity:
Marital Status:
Residential Status:
Primary Language:
If other:
Religion:
If other:
LGBT Status:

Section VI: Insurance
Do you have insurance?
Insurance Details
Insured's Name:

First NameLast Name
If Not Client, Relationship to Client:
Insurance Type:
Other:
Policy Number:
If Not Client, Insured's Social Security Number:
If Not Client, Insured's Date of Birth:

MonthDayYear
Date

Section VII: Employment
Employment Status:
Annual Income:
Primary Source of Income:
Income for Past 30 Days:
Number of Days Worked in Past 30 Days:
SSI/SSDI Eligibility: :
Monthly SSI/SSDI Income:
Annual SSI/SSDI Income:
Other Source of Income:
If Other:
Total Annual Household Income:
Total Number of Dependents (including children and yourself):
Are You Disabled:
Do You Receive Food Stamps:
Who Pays Your Mortgage:
Who Buys Your Food:

Section VIII: Extended Profile
Is Client Disabled:
Is Client Non-Ambulatory:
Is Client Visually Impaired:
Is Client Hearing Impaired:
Does Client Know Limited English:

Section IX: Brief History
Have you received services at New Horizons in the past:
Briefly, why are you seeking services at this time:
How long has this been a problem:
What have you attempted to do about this so far:

New Horizons Outpatient Services Handbook
Click below to enlarge or print.
Please acknowledge receipt of handbook: *

Section X: Consent Forms
1. Consent for Treatment
I am a consumer of New Horizons of the Treasure Coast, Inc.I am a parent/guardian/guardian/advocate of the consumer of New Horizons of the Treasure Coast, Inc.
I, as a consumer of New Horizons of the Treasure Coast, Inc. or the parent/guardian/guardian advocate of the subject of this consent, hereby give consent to the professional staff of New Horizons to administer treatment.

Treatment/Services may include crisis stabilization, residential, individual, group, or family therapy, psychiatric services, case management, community support, and ongoing needs assessment. The purpose of treatment/services is to facilitate the recovery process.

I understand that Treatment/Services may be provided via Telehealth or Telepsychiatry, and American Sign Language (ASL) Services via Video Remote Interpretation are available and may be needed for effective communication.

I will be informed of the nature and purpose of treatment, its common side effects, alternative treatment modalities, and the approximate length of care. I will also be informed that consent can be revoked orally or in writing before or during the treatment period.

Psychotropic meds may be offered; however, medications will be discussed on a case-by-case basis and will require additional consent from the patient, parent, or guardian. New Horizons does not offer electroconvulsive treatment or any surgical treatment requiring the use of an anesthetic at this time.

In addition, I understand that New Horizons may need to report my data to any of their funders for statistical reporting and Quality Assurance.

I have read and fully understand the above Consent for Treatment. No guarantee or assurance has been given regarding the results that may be obtained from the treatment/services I receive at New Horizons.
Print Name:

First NameLast Name
Initials:
Signature (you may be asked to sign again at your first appointment):

Clear
Today's Date

MonthDayYear
Date
2. Consent to Follow-Up Survey

Informed consent to be contacted regarding services received.
I Consent to a Follow-up Survey:
Survey Contact Name:

First NameLast Name
Survey Contact Primary Number:
Please enter a valid phone number.Format: (000) 000-0000.
Survey Contact Secondary Number :
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact Name:

First NameLast Name
Primary Contact Number:
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact Number:
Please enter a valid phone number.Format: (000) 000-0000.
Accepted for Services:
Contact's Relationship:
Complete:
Internal Contact Info:
MR #:
Entered in JotForm by:
Staff ID

New Horizons New Client Registration Form

Section I. Required documents:

Section II: Client Information

Section III: Children Only

Section IV: Demographics

Section VI: Insurance

Insurance Details

Section VII: Employment

Section VIII: Extended Profile

Section IX: Brief History

New Horizons Outpatient Services Handbook

Section X: Consent Forms

1. Consent for Treatment

2. Consent to Follow-Up Survey