New Patient Information

Welcome to the Practice!

Want to become a patient? Please call us at 401.681.4274 between 9am and 5pm to speak to an intake coordinator.

To avoid having to arrive 20 minutes early to your first appointment please fill out the forms, save, and send to: info@qbhri.com

• Patient Interview Sheet
• Rules of Practice 
• Patient Informed Consent for Treatment
• HIPAA Notice of Privacy Practices
• HIPAA Signature Form
• Patient Past Medical History Form
• Current Care Form 
• QuitWorks Form
• PCP Release Form

Also fill out and bring the forms in this list that apply to you:

 

DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure Child 11-17

DSM-5 Parent.Gaurdian Rated Level 1 Cross-Cutting Symptom Measure Child 6-17

DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure Adult

DCYF Packet