BHS Intake Forms

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Tele-Behavioral Health

To those we are currently serving,

During these most unprecedented of times in our community and country – Youth For Tomorrow’s Behavioral Health Services remains committed and available to you and your family. We understand for your family, as well as ours, the daily uncertainty and in many respects significant life changes we are all having to make can bring with it even added layers of struggle and stress. We are here for you!

We remain humbled by the trust you have placed in us to provide Behavioral Health Care services. In an effort to not hinder our care for you, our availability to you, and our on-going delivery of compassionate care through counseling and/or medication management, we are implementing Youth For Tomorrow’s Tele-Behavioral Health services effective Monday March 23rd.

For current clients, this allows you to maintain the personal connection with your same provider in the comfort and safety of their own home.

We understand that for some this may be a new way of connecting with your clinician. We may also experience some initial technical glitches along this new journey as our nation’s overall internet usage is being leveraged more than ever.

Regardless, we care for you and are committed to walking this life’s journey together.

Sincerely,

Youth For Tomorrow Leadership

New Client Forms 

#1 Client Contact Information - Click here to DocuSign this form

#2 Tele-Behavioral Health Agreement - Click here to DocuSign this form

#3 BHS Rights and Responsibilities - Click here to DocuSign this form

#4 BHS HIPPA Acknowledgement - Click here to DocuSign this form

#5 Authorization to Release Health Information - Click here to DocuSign this form

Tele-Behavioral Health Service Agreement For Existing Clients 

This form is for existing clients and is an addendum to the face to-face informed consent in the Service Agreement you have already signed during the intake.

IMPORTANT! To return this form you have three options - 

Electronically - Please complete the form securely on DocuSign. 

Click here to begin - Tele-Behavioral Health Service Agreement

By fax - You can fax the completed form to 540-935-2418

Click here to download the PDF form for fax or mail. 

By mail - Please mail the completed form to us here -

Youth For Tomorrow, Behavioral Health Services
20 Rock Pointe Lane, Suite 201
Warrenton, VA 20186

Please note that we will begin accepting new clients for these services as quickly as possible. 

Existing Clients - Consent to Medication Management

Click here to sign the Consent to Medication Management - Please note this form is for existing clients. 

Additional Form for all Current Clients

Authorization to Release Personal Health Information

If there is a third party involved in your treatment (or your child’s treatment) with whom it would be helpful for YFT to communicate (e.g. school guidance counselor, primary care physician, previous therapist, other family members or supports, etc.), it is your choice if you would like to authorize us to exchange information with that individual or organization. Please fill out as many of these forms as needed and give them to your assigned therapist. To begin click here