Outpatient/IOP Admission PacketOutpatient/Iop Admission Packet • January 27th, 2015 • California
(if used) Credit Card Authorization General Information Family Information-Parents Family Information-Siblings Family Questionnaire Educational Information Treatment History Medical History Medications Physicians Signature Physical Exam Enrollment Agreement OPI Rules and Precepts Authorization to Release Info to OPI Authorization for OPI to Release Info Activities Release Release of Liability Complete Release of Liability – Off Premises Notice of Privacy Practices Letter of Agreement Regarding the Provision of IndividualPsychiatric Consultative Services Letter of Agreement Regarding the Provisions of Individual Psychotherapy Services Cancellation/No Show Policy Statement of Authenticity
