* Required Information
Emergency Contact

I authorize You First Health and Wellness Services LLC to contact the above-named person in case of an emergency.

Pharmacy Information
LIST ALL PSYCHIATRIC MEDICATIONS THAT YOU ARE CURRENTLY TAKING
Patient-Provider Authorizations and Agreements.

Authorizations and Agreements with You First Health and Wellness Services LLC. Please read carefully and sign. The paragraphs below contain several agreements.

Financial Responsibility

I understand and agree that I am responsible for the fees to You First Health and Wellness Services LLC before services are rendered.

Primary Care Physician Contact Authorization

I, (Print Name) hereby authorize You First Health and Wellness Services LLC

I may revoke this authorization at any time except to the extent that action has been taken in reliance upon it. If I do not revoke this authorization, it will expire one (1) year after I have terminated treatment.

Informed Consent For Treatment

(name of patient), agree and consent to participate in behavioral healthcare services offered and provided by You First Health and Wellness Services LLC, a behavioral health care provider. I understand that I am consenting and agreeing only to those services that the above-named provider is qualified to provide within: (1) the scope of the provider's license, certification, and training; or (2) within scope of license, certification, and training of the behavioral health care provider directly supervising the services received by the patient.

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.

Select a country first.