New Client Admission
Ability and Empowerment Services, INC
1 N Charles Street, Baltimore, MD 21201
Before you begin
This replaces the paper admission packet. It takes about 15 minutes, and it covers every form the clinic needs: both consents to treatment, the intake questionnaire, your emergency contacts, HIPAA, telehealth, and information sharing.
You only enter each answer once. Your name, date of birth, address and insurance are carried across every form, and you sign a single time at the end.
Your answers are saved as you go. Close the page and pick up where you stopped.
Unfinished form
We found answers you started earlier.
Confidential. Protected health information.
If you are in crisis, call or text 988.
About you
Who you are.
Your name
How we reach you
How we reach you.
How we reach you
Your address
Insurance and photos
Your coverage, and the cards in your hand.
Insurance and referral
Photographs
The whole card in frame, text readable.
Your care team
Who we call if something happens.
Emergency contact
Second emergency contact
Your doctor
Who looks after your body.
Your doctor
If not, we stop asking here.
Allergies and conditions
Your health
None of this changes whether you are accepted.
Physical health and sleep
How you have been feeling
No wrong answers here.
Previous care
Mood, anxiety and pain
Alcohol and substances
Relationships and family
The people around you.
Relationships and recent events
Family mental health history
Tap what runs in your family.
A little more about you
What you bring, and what you want.
Work and beliefs
You, in your own words
Tap what sounds like you.
Where you come from
Skip anything you would rather not answer.
Family of origin
Sharing your information
Who else may see your file, and what.
Another therapist, a doctor, a case manager, a school, a court.
Who we may exchange with
What may be exchanged
Tap only what you agree to share.
Supervision
Your therapist may be supervised.
Review and sign
One signature covers every document in your packet.
What you told us
The forms you are signing
Scroll to the end of all seven.
Your signature
Parent or legal guardian
Witness
Staff use only
Staff only. Clients: submit now.
Screening
Determination
Timeliness
Screening is delayed due to:
Staff name and title completing this screening
Filing your packet
Your documents are already made on this phone. We are filing them with the clinic now. Please keep this page open.
Your packet is filed
Ability and Empowerment Services has your admission packet. Download your own copy below and keep it.
Reference