Murray Center for Behavioral Wellness 29500 Southfield Rd. Suite 100 Southfield, Michigan 48076

Ph: 248.962.3040 Fax: 248.504.5642 inquiry@murraycenter.com murraycenter.com

Date: ___________________

Patient’s Name: ________________________________________________________________

Address: ______________________________________________________________________

______________________________________________________________________________

Phone (home): __________________ (work): __________________ (cell): _________________

Date of Birth: ___________________ Gender: ___Male ___Female Age: _____

Guardian (for children and adults when applicable): _________________________________

Marital Status (check one): Race (optional):

___ Never married ___ Divorced ___White ___Native American

___ Married ___Separated ___African-American ___Asian

___ Widowed ___Cohabiting ___Hispanic ___Other

Family Members:

Name/Age/Gender/Relationship

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Employer: _________________________ Occupation: ______________________________

School (for children, and adults when applicable): _________________________________

Grade: ___________________

Referral Source: _____________________________________________________________

Pediatrician/physician: ________________________________________________________

Emergency Information:

Name of Emergency Contact: ____________________________Phone: _________________

Relationship to Patient: _______________________________________________

Insurance Information (Blue Cross Blue Shield Members only):

Name of Insured/Subscriber: _______________________________ DOB of Subscriber: _____________

Policy ID#__________________________ Policy Group#_______________________

Murray Center for Behavioral Wellness 29516 Southfield Rd. Suite 100 Soutfield, Michigan 48076

Ph: 248.962.3040 Fax: 248.504.5642 inquiry@murraycenter.com www.murraycenter.com

Your signature below indicates you have read and agree to the following:

CONSENT TO TREAT/AGREEMENT TO POLICIES I understand and agree to the Policies and Procedures and understand that a copy of the “Policies and

Procedures” is available to me and hereby request and authorize Murray Center practice providers to

provide behavioral health services/treatment to me or my dependent (if patient is a minor). I understand

that behavioral health services/treatment may include psychological assessment, psychotherapy, or

medication treatment. I am agreeing only to those services that the practice providers are qualified to

provide within the scope of the provider’(s) license, certification, and training or the scope of those

provider(s) directly supervising the services received by me. I also understand that, at any time, I can

terminate this consent for treatment by putting such request in writing.

FINANCIAL AGREEMENT As a BCBSM subscriber I understand that I am responsible for informing the practice of my insurance

coverage and verifying my own benefits. I understand that I am responsible for all charges for services

provided to me, other than those covered by BCBSM. I will pay my balance in full, at the time of service,

for all services rendered on my behalf or my dependent’s behalf that are owed. Upon request, a receipt

will be provided that I can file with my insurance provider for reimbursement.

NOTICE OF PRIVACY POLICIES

I hereby acknowledge that I have been offered a copy of the “Notice of Privacy Policies” and understand

the information included in this document. I am aware that a copy of this notice will be given to me when

I ask for a copy.

AUTHORIZATIONS FOR COMMUNICATION

For each of the following, please indicate your preference by initialing the appropriate statement:

Telephone Messages

I authorize that telephone messages regarding my appointment times may be left on my (please

initial/check beside “Yes” or “No” for each item):

Home answering machine/voicemail _____Yes _____No

Work voicemail _____Yes _____No

Cell phone voicemail _____Yes _____No

Email Communications

___ I do not consent to sending and/or receiving email communications during the course of my

treatment.

___ I consent to sending and/or receiving email communications as part of treatment, including pdf files. I

understand the risks of sending PHI through email, and with this agreement I am accepting these risks. I

understand that I can terminate this agreement at any time by informing Dr. Murray/Dr. Fallucca in

writing.

Email address (print): __________________________________

Text Messages

___ I do not consent to sending and/or receiving text messages as part of my treatment.

___ I consent to receive text messages to the mobile telephone below. I will advise the practice if I change

my mobile number and understand that a new consent form is required. I understand that I can terminate

this agreement at any time by informing Dr. Murray/Dr. Fallucca in writing. By consenting to text

2

messaging, I believe that the benefits for my healthcare outweigh the security risks. Mobile Number to

receive text messages: (_____)___________________

Name of patient: __________________________

Signature: __________________________________ Date: __________________________

Please describe your relationship to the individual and /or your legal authority to act on behalf of

this individual in making decisions related to healthcare. You may be asked to provide us with

relevant legal document giving you this authority.

Relationship to the individual (required): _________________________________________

Murray Center for Behavioral Wellness

29516 Southfield Rd. Suite 100 Soutfield, Michigan 48076

Ph: 248.962.3040 Fax: 248.504.5642 inquiry@murraycenter.com www.murraycenter.com

Credit Card Authorization Form

Patient Name: _______________________________________

Patient Birthdate: ___________________________

Credit Card Type (Circle One): MasterCard Visa Discover American Express

Credit Card Number:___________________________________________

Expiration Date: ___________________________

CCV: ____________________

Credit Card Holder's Name as it Appears on Card: __________________________________________

Billing Address: ______________________________________________________________

City: _______________________________________ State: _________________ Zip: __________

Card Holder Phone Number: __________________________________________

On______________________ (insert today's date) I authorize Sarah Murray, Ph.D. to initiate a recurring charge to the credit card indicated above for any outstanding charges after each visit (for any visit not paid the day of service). I understand I will only be charged for completed appointments and any late cancellation fees when an appointment is cancelled with less than 24 hours’ notice (or 48 hours for testing appointments).

I understand that I may cancel my recurring charge upon written notice to Sarah Murray, Ph.D. by writing to 29516 Southfield Rd Suite 100 Southfield, MI 48076.

If you have any questions about this transaction or if the credit card indicated above is lost or stolen, I agree to notify Sarah Murray, Ph.D. at once by calling at 248-962-3040 or by contacting her by mail or email.

Card Holder Signature____________________________________ Date____________________