Group Only Referral Form and Provider Agreement

Participant Name*

First Last

Date of Birth*

Participant Phone*

Participant email*

Participant Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Outside of NW ADHD Behavioral Health Provider Name (If you are a current NW ADHD Patient, list your NW ADHD provider)*

First Last

Outside Provider Phone*

Outside Provider Fax

Outside Provider E-mail

Outside Provider Practice Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Participant Insurance*

Participant Insurance ID*

Name of group(s) interested in attending:*

Consent*

I, as an individual seeking group treatment at Northwest ADHD Treatment Center, agree to the following:

By seeking engagement in group services only, I understand that I am required to have and maintain engagement with a behavioral health provider outside of Northwest ADHD Treatment Center at least for the full duration of my participation in a group at Northwest ADHD Treatment Center. I have informed my outside behavioral health provider about my participation in this group, and my outside behavioral health provider has confirmed that my participation in a group at Northwest ADHD Treatment Center is consistent with my treatment plan.

I understand that my outside behavioral health provider, not Northwest ADHD Treatment Center, is responsible for my mental health care in the event of an emergency or crisis.

I understand that by completing this form, I not eligible to meet with a Northwest ADHD Treatment Center provider for individual therapy, medication management, ADHD assessment, or other services outside of group therapy. I understand that if I wish to engage in other services at Northwest ADHD Treatment Center, a separate referral form for those services, completed by my referring provider, is required. I understand that other services at Northwest ADHD Treatment Center may have significant wait times before services may become available.

I understand that for attending groups that meet via a telehealth platform, I must be physically within the state of Oregon in order to participate.

I have spoken with my outside behavioral health provider, and we both understand that my outside behavioral health provider will:

1. Assume full clinical responsibility for my care, and acknowledge that Northwest ADHD Treatment Center providers are not responsible for my client’s care outside of group therapy.

2. Handle or provide backup services to manage client clinical emergencies.

3. Consult with Northwest ADHD Treatment Center as is appropriate, including sharing relevant clinical records, including a valid release of information for mutual coordination of care.

Group Only Referral Form and Agreement