Forms


 

PLEASE READ AND COMPLETE THE NECESSARY FORMS

New Patient ONLY:

1. Welcome Packet / Paquete de Bienvenida


Authorization Forms:

2. Authorization to Release or Obtain Confidential Information   

3. Telemedicine Authorization Form / Formulario de Autorización de Telemedicina


Establish Patient - Changes/Updates Forms:

4. Annual Update / Actualización Anual

5. Demographic Update / Actualización Demográfica 

6. Consent for Treatment / Consentimiento para Tratamiento

7. PCP and Pharmacy Information / Información De Medico Primario y Farmacia


Scales:

8. PHQ-9 / GAD-7

9. Vanderbilt for Parents / Vanderbilt para Padres

10. Vanderbilt for Teacher

11. Vanderbilt for Follow-up Parents / Vanderbilt para Padres de
Seguimiento

12. Vanderbilt for Follow-up Teacher   

13. ADHD for Adults

14. Weekly Sleep Questionnaire / Cuestionario Semanal de Sueno


Sliding Fee Discount Program:

If you are applying for our Sliding Fee Discount Program, you will need to complete the following:

Sliding Fee Discount Application                                         

  • List all family members and dependents living in your household.
  • A Family is one or more persons living in one dwelling place who are related by blood, marriage, or law.
  • A Dependent is someone who lives in your household and qualifies as a dependent for federal tax purposes. 

Proof of Income (POI):

You will also need proof of income for all working family members for the past 30 days. We accept check stubs, SSI or Disability award letters, Child Support or Alimony orders, or Unemployment compensation. If you do not have any of these, the following alternative options may apply:

If you do not receive check stubs or have recently started a new job, please have your employer complete this form. It must be dated within fourteen (14) days of your scheduled appointment.

This is a signed form indicating your net income for the past month. You will also need to provide all of the following:

  • Pages 1 and 2 from Current Year Tax Returns
  • Schedule C, E, or F from Current Year Tax Returns
  • Bank statement from the past 30 days

Alternative Income Form

This is a signed form indicating that someone is supporting you at this time. To be eligible to use this form you must be:

  • Eighteen (18) or older
  • Unemployed
  • Supported by another individual (cannot be a spouse) 
Location
Esperanza Behavioral Health and Services
7350 Futures Drive, Suite 16
Orlando, FL 32819
Phone: 689-219-5862
Fax: 407-226-3734
Office Hours

Get in touch

689-219-5862