Patient Forms and Resources

New Client Forms

Use this form to request a new patient appointment.

Temah Mental Health Web Intake Form for Pediatrics

Temah Family Practice Web Intake Form for Pediatrics

Temah Mental Health Web Intake Form for Adults

Temah Family Practice Web Intake Form for Adults

Referral Forms

Providers should utilize these forms to refer their client for services.

PRP Referral Form for Children/Adolescent

PRP Referral Form for
Adults

Patient Referral
Form

Testing for ADHD/ADD Request Form

Prescription Refill

Utilize this form to request medication refills and out-of-state prescriptions.

Use this form to request an assessment/
testing.

Utilize this form to request Housecall services.

Authorize THS to share your medical information with another agency or individual by completing this form.

Complete this form if you are interested in a Graduate Internship.

Utilize this link to access the necessary resources.

Patient Forms and Resources

Use this form to request a new patient therapy appointment.

Use this form to request an assessment/
testing.

Give THS permission to send your medical information to another agency or person using this form.

Our informed consent gives you information about THS services, confidentiality, benefits and risks of treatment, payment options, and agency policies.

Rights and expectations of THS
patients can be found
in this document.

Please submit your questions using this form. If you are requesting an appointment, please submit through the New Appointment Request form above.

Please see our professional disclosures for licensed therapists still under supervision.

Find information here about
advance directives.

Content

Health Forms Policies

Health Forms Policy

Our foremost goal is to ensure that our patients are thoroughly informed about the necessary requirements and expectations when they seek to have their Health Forms completed by their healthcare provider. Our utmost focus is on building a meaningful and enduring connection between our patients and their healthcare providers before initiating the process of Health Form completion.

Client Eligibility:

To qualify for your healthcare provider at our clinic to complete your Health Forms or write letters on your behalf, you must fulfill specific eligibility criteria, including a minimum requirement of at least two months of active engagement with our clinic as a patient.

Appointment Commitment:

Maintaining regular attendance at all scheduled appointments during your initial two-month period as an established patient is vital. This commitment is key to nurturing a robust patient-provider relationship and ensuring the accuracy of your medical records.

Treatment Compliance:

It is crucial for effective care that patients strictly adhere to the prescribed treatment plan, which may involve medication management and/or psychotherapy, during the initial two-month period.

Follow-Up Care:

Patients are encouraged to faithfully adhere to all medication prescriptions and guidance given by their doctor at our clinic. This may encompass dietary modifications, exercise regimens, and other lifestyle adjustments aimed at improving overall health.

Requesting Health Forms:

Once you have a documented two-month patient history at our clinic and have consistently attended all follow-up appointments, you are eligible to request the completion of your Health Forms. Please carefully follow the provided instructions to initiate this process. It’s important to note that there is an associated Health Form administrative fee, and the fee amount may vary depending on the complexity and length of the forms, ranging from $70 to $140.

Completion Timeline:

After you have submitted your request for Health Forms completion, kindly anticipate a processing period of up to 10 business days for the finalization and completion of the process.

Patient Responsibilities:

It is your responsibility to ensure that you provide all necessary information and make the required payment to prevent any processing delays. The 10-business-day completion timeframe begins upon receipt of payment. Failure to make the payment or provide necessary information may lead to delays in the completion process.

Our dedication lies in delivering high-quality care and enhancing the well-being of our patients. This policy has been crafted to guarantee that our patients receive the best possible care, with Health Forms completed accurately and in full compliance with legal requirements

This policy also encompasses short-term disability forms and any other work-related forms that may be relevant.

No Show and Cancellation Policies

No-Show and Cancellation Policy

At Temah Healthcare Services, we are committed to providing timely and quality healthcare services to all our patients. To ensure the availability of appointments for all patients and to minimize disruptions to our healthcare schedule, we have implemented the following No-Show and Cancellation Policy:

1. Appointment Confirmation:

Patients are encouraged to confirm their appointments in advance through the preferred method specified by our clinic, whether it be phone, email, or our online booking system.

2. Cancellation Notice:

We understand that unforeseen circumstances may arise, and you may need to cancel or reschedule your appointment. We kindly request that you provide us with at least 24 hours notice if you need to cancel or reschedule your appointment. This allows us to accommodate other patients in need of care.

3. No-Show Policy:

A “No-Show” is defined as a patient who misses their scheduled appointment without providing prior notice or who arrives excessively late, making it impossible to be seen.
Patients who fail to show up for their appointments without prior notice will be considered “No-Shows.”

4. No-Show Fee:

A No-Show Fee of $70 will be charged to the patient’s account for each missed appointment or late cancellation without proper notice.
The No-Show Fee must be paid before scheduling any future appointments.

5. Exceptions:

We understand that emergencies can happen, and exceptions may be made on a case-by-case basis at the discretion of the clinic management. Please contact us as soon as possible if you encounter an emergency that prevents you from attending your appointment.

6. Repeated No-Shows:

Patients with a history of repeated No-Shows may be subject to additional measures, including possible discharge from our clinic.

7. Rescheduling:

If you need to reschedule an appointment, please contact us as soon as possible. We will make every effort to accommodate your request and find an alternative appointment time.

8. Online Booking:

Patients who book appointments through our online booking system are also subject to this No-Show and Cancellation Policy. It is their responsibility to cancel or reschedule appointments online within the specified notice period.

By scheduling an appointment at [Your Clinic/Hospital Name], you agree to abide by our No-Show and Cancellation Policy. We value your cooperation in helping us provide efficient and accessible healthcare services to all our patients. Your understanding and adherence to this policy are greatly appreciated.

If you have any questions or need to cancel or reschedule an appointment, please contact us at 410-521-8000

Thank you for choosing Temah Healthcare Services, LLC for your healthcare needs.

Use this form to request a new patient therapy appointment. Wait times fluctuate based on the service requested and time of year.

Use this form to request an assessment/testing. Wait times fluctuate based on the service requested and time of year.

Give iHEAL permission to send your medical information to another agency or person using this form.

Our informed consent gives you information about iHEAL services, confidentiality, benefits and risks of treatment, payment options, and agency policies.

Rights and expectations of iHEAL patients can be found in this document.

Please submit your questions using this form. If you are requesting an appointment, please submit through the New Appointment Request form above.

Please see our professional disclosures for licensed therapists still under supervision.

Find information here about advance directives.

Online Temah Intake Form

Patient Information

Demographic

Chief Complians

Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Is It the Same as Mailing Address? *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Date of Birth*

Email *

Soc. Sec. *

Marital Status

Sex/Gender

State ID / Drivers License ID

Layout

Cell Phone *

Home Phone *

Layout

Race

Hispanic or Latino Descent *

Power of Attorney & Emergency Contact

Power of Attorney / Guardian

Layout

P.O.A Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Fax #

Relationship to Patient

Emergency Contact

Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Relationship to Patient

Primary Insurance

Name *

First

Last

Claim Address

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Policy/ID Number

Group Number

Soc. Sec. Number *

Secondary Insurance

Name (copy) *

First

Last

Claim Address

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Policy/ID Number

Group Number

Primary Physician

Name *

First

Last

Layout

Phone *

Fax

Pharmacy

Layout

Name *

Phone *

Zip Code

Fax

Therapist

Name *

First

Last

Layout

Phone *

Fax

Other Provider

Name *

First

Last

Layout

Phone *

Fax

Layout

Insurance ID

Click or drag a file to this area to upload.

State/Driver's ID

Click or drag a file to this area to upload.

Please provide a photocopy of each side of your insurance card(s) – front and back and a photo identification card.

Patient Forms and Resources

New Client Forms

Referral Forms

Prescription Refill

Patient Forms and Resources

Health Forms Policies

Health Forms Policy

Client Eligibility:

Appointment Commitment:

Treatment Compliance:

Follow-Up Care:

Requesting Health Forms:

Completion Timeline:

Patient Responsibilities:

No Show and Cancellation Policies

No-Show and Cancellation Policy

1. Appointment Confirmation:

2. Cancellation Notice:

3. No-Show Policy:

4. No-Show Fee:

5. Exceptions:

6. Repeated No-Shows:

7. Rescheduling:

8. Online Booking:

Online Temah Intake Form

Demographic

Power of Attorney & Emergency Contact

Power of Attorney / Guardian

Emergency Contact

Primary Insurance

Secondary Insurance

Primary Physician

Pharmacy

Therapist

Other Provider

Keep in Touch with Us

Our Contact Details

410-521-8000 / 443-272-2572

Office:

Quick Links

Business Hours

410-521-8000 /
443-272-2572