New Patient Forms

 

New patients will need to first click this link to access and download the forms,

then follow the instructions at the bottom of this page for each form. 

Bay Counseling Services will also need a copy of the patient's insurance card

and a photo ID (most patients provide a driver's license).

 

Please return forms by one of the following methods: 

Email: bay21222@aol.com

Fax: (410-569-6500)

Standard mail:

Bel Air office

Emmorton Professional Center

2107 Laurel Bush Road Suite 209

Bel Air, MD 21015

In Person: Forms may be dropped off at the Bel Air location.

Explanation of New Patient Forms:

 

Member's Rights and Responsibilities (for your personal records)

This form outlines what BCS expects from the patient and what the patient can expect from BCS

during treatment.

 

Informed Consent for Treatment (Sign and date)

This consent form acknowledges that the patient is giving permission for the clinician to evaluate

and recommend treatment.

 

Fee Agreement (Initial, sign and date - 2 pages in length):

Page 1 outlines our fee structure and the patient needs to initial next to each paragraph. 

Page 2 contains important administrative policies.  Patient should sign and date where indicated. 

If a parent/guardian is signing for a child, the signee needs to include his/her date of birth.

 

Patient Care Communication (Fill out boxes, check, sign and date):

This form may allow the clinician the right to communicate with the patient's PCP or, if a child, the child's pediatrician. Please include the name of the doctor, the doctor's address and phone number filled in the top section and then check whether or not we can communicate with the doctor. Regardless of option chosen, please sign and date.

 

HICFA (Fill out Question 10, check, sign and date):

The HICFA form allows us to electronically bill the claims to the insurance company. The patient only needs to answer question #10 and sign, date and sign the middle section of the form. Please leave bottom section blank.