Benjamin's Behavioural Health Services

9701 Richmond Avenue   Ste 210   Houston Tx.   77042     Phone: 713.840.7956   Fax: 713.840.7957


We would like to take this opportunity to thank you for your confidence in choosing Benjamin's Behavioral Health Services, PLLC for professional services. Since our goal is to provide you with the best service possible, and in order to serve you more effectively, we ask that you read the following information relevant to treatment, confidentiality and office policies. 

Aims and Goals:
At Benjamin's Behavioral Health Services, we believe in gentle, collaborative partnership with our patients to help them reach happiness, and true well-being. Our main goal is to treat each individual as a whole by identifying unique needs before setting forward a treatment plan tailored to those specific needs.

This goal is accomplished by:                        
        1. Increasing personal awareness.                       
        2. Increasing personal responsibility and acceptance to make changes necessary to attain your goals.                       
        3. Identifying personal treatment goals. 

You are responsible for providing necessary information to facilitate effective treatment. You are expected to play an active role in your treatment by attending All of your scheduled appointments on time and working with your provider to outline your treatment goals and assess your progress. There may also be negative consequences if you do not follow through with recommended treatment(s).

You may be asked to complete questionnaires, and random multi-panel urine drug tests will accur. Your progress often depends much more on what you do between sessions, than on what happens in the session


Office Policies and Procedures
*Please read thoroughly and initial next to each statement to indicate your understanding and agreement.

 Record Keeping:
A clinical chart is maintained describing your condition and your treatment and progress in treatment, dates of appointments, fees for sessions and notes describing each session. Your records will not be released without your written consent, unless in those situations as outlined in the Confidentiality Agreement section above.

 Cancellations, Missed, and Same Day Re-scheduling Appointments
Once your appointment is scheduled, you will be expected to pay for the office visit for it unless you confirm with one following:
1. New Patient Appointments: MINIMUM 48 BUSINESS HRS (2 BUSINESS DAYS) NOTICE (WEEKENDS ARE NOT INCLUDED) New Patient Appointmemnts- If not compliant with plicy, them the full cost of the appointment is due: $385 will be charged from the card on file

2. ​​​​Established/Follow Up Appointments: MINIMUM 48 BUSINESS HRS (2 BUSINESS DAYS) NOTICE (WEEKENDS ARE NOT INCLUDED) Established/Follow Up Appointments- If not compliant with policy, then the full cost of the appointment is due: $150 will be charged form the card on file.

3. Rescheduled Appointments MINIMUM 48 BUSINESS HRS(2 BUSINESS DAYS) NOTICE If not rescheduled in advance, then the following applies: 
a. Same Day Rescheduling: $150 will be charged to the card on file 
b. Within 24 Business Hours (1 Business Day): $100 will be charged to card on file 
c. Valid Methods To Cancel or Reschdule Appointments: Email: Call the office: 713-840-7956 (MTH: 9am to 5pm, FRI: 9am to 3pm) Fax: 713-840-7957 or In Person

 After Hours Contact
In the event of un urgent psychiatric matter outside of regular hours you may contact the on-call provider by call the office and following the appropriate prompts on our telephone operator.
a. This service is for emergencies ONLY that cannot wait till the next business day (i.e., suicidal thoughts, thoughts of harming others, serious medication reactions, or unusual bahavior that may be of harm to yourself or others). Non-emergency matters (i.e., medication refills, schedulling or billing issues) must be addressed via email or by leaving a voicemail message for clinic staff.
b. Calls Placed for non-emergency issues will result in being chared a $50 fee for afterhours care

 Insurance Changes, Billing and Payments Policy:
a. Notification to the office of 2 Business days is
REQUIRED prior to your appointment with ANY cahnge of insurance. The office cannot verify your insurance for mental health benefits the day of your appointment. Even if your insurance requires "no-precertification" or there is no deductible, the office cannot verify benefits on the day of your visit. If notification is not giving to the office within 2 Business days in advance to your appointment, the "full fee" for your visit will be due. Unless, the office manager and/or the supervising doctor modifies this policy. This will be the only notification that will be received.

b. Our office accepts several commercial insurances only. Our office DOES NOT file insurance claim forms for insurances we are not contracted and credentialed with. We will be glad to give you a receipt, which includes all of the information necessary for filing claims with your insuranance company.​​​​​
i. As a courtesy to you, we will bill your primary insurance company directly for medical services rendered. While we make a good faith attempt to verify coverage, we are not able to guarantee that the information fiven to us by your insurance is correct. We encourage you to call your insurance plan directly if you have any questions about covered services.
ii. In addition, you will be responsible for payment of all non-covered services at the time thay are rendered. If your insurance subsequently pays for services that were first treated as non-covered, you will be reimbursed. Know that it is your responsibililty to notify our office if your have any insurance changes
iii. All office fees are due at the tome service (co=payments, deductibles, non-covered services, lack of medical coverage). This office accepts cash, MasterCard, Visa, Discover, American Express and debit cards for your convenience. Our office does NOT accept checks. If your account has payment overdue for over 60 days, we have the option of using legal means to secure payment, including collection agencies or small claims court. In most cases, the only information we would be providing would be your name, nature of services provided, and amount due.

 Termination of Care
At times, termination of care between a patient and provider is necessary. Termination of care may occur at any given time and may be initiated by either the patient or the provider.

 Confidentiality Agreement:
Issues discussed with your provider are important and are generally legally protected as both confidential and “privileged.” However, there are limits to the privilege of confidentiality. These situations include: 1) Suspected abuse or neglect of a child, elderly person or a disabled person, 2) when the doctor believes you are in danger of harming yourself or another person, or you are unable to care for yourself, 3) if you report that you intend to physically injure someone the law requires the doctor to inform that person as well as the legal authorities, 4) if the doctor is ordered by a court to release information as part of a legal involvement in company litigation, etc., 5) when your insurance company is involved, e.g. in filing a claim, insurance audits, case review or appeals, etc., 6) in natural disasters whereby protected records may become exposed or, 7) when otherwise required by law. You may be asked to sign a Release of Information so that the doctor may speak with other mental health professionals or to family members. 

If you are concerned about some of your information, you have a right to ask us, to not use or share some of your information for treatment, payment or administrative purposes. Such request must be made by writing. 

After you have signed the Consent Form, you have the right to revoke it at any time, by writing a letter informing us that you no longer consent to the use and disclosure of your Personal Health Information. On receipt of your letter, we will comply with your wishes about using or sharing your information from that time on. 
  • Late Arrival to Appointments is NOT permitted: If you arrive more than 10 minutes to your scheduled appointment you MAY be asked to reschedule for another day and time: SAME DAY  rescheduling fee of $150 will be charged to the card on file. Any amount of time that you are late to your appointment will be deducted from the TOTAL TIME slot you are scheduled for. Additionally, you understand that you may be seen by a different Medical Doctor or Nurse Practitioner on this appointment.
  • Please note that insurance companies will often NOT reimburse for missed appointments or appointments that are cancelled late.
  • We realize no one can predict emergencies or disasters. Courtesy is however, requested. If you arrive more than 10 minutes late, please be aware that there is the possibility that your appointment may be reschduled, as not to inconvenience the next scheduled patient.
  • Please note than in the event of a missed, rescheduled, or cancelled appointment, your medications may not be refilled.
  • Also, reminder calls/texts/emails are a courtesy. You are responsible for your appointment whether your reminder was received or not
 Appointment Reminders
Text message, e-mail, and telephone reminders are a courtesy service only. You are responsible for your appointment Whether a reminder is received or not.

Emails: Please remember that email has the privacy of a postcard. Before you send an email, be cautious with what you're disclosing. Emails cannot be a means of managing a crisis, since one cannot always be aware email arrival. Neither, can one have access to email on a permanent basis. If it is a medical emergency, please contact 911. Otherwise, We can still be contacted via emaikl for non-immediate matters.

 Voicemail Messages:
Please be aware that we are not in the office every day, but do commit to return your voicemail messages within two business day. If you have a life-threatening emergency, experience worry that you will hurt or kill yourself, or have a concern that you are going to hurt or kill someone else, please leave us a message and call 911 immediately. We suggest leaving hospital emergency department, law enforcement, and poison control numbers by your telephone or programming them into your cell phone.

Faxes: Faxes are reviewed during normal business hours and are responded within 72 hours. Priority of requested medications from pharmacy are taken into consideration when responding to each fax. Medication changes will not be accepted.

 Forms, Letter & Other Professional Services
Any other professional services that requires longer than 5 minutes such as:
a) report writing, B) telephone conversations (non-emergency), preparation of treatment summaries, or d) time spent performing any other service that will be charged $95.00 for each 10-minutes increment, like the fee for treatment
i) ONLY with prior medical physician approval, Temporary Disability and FMLA paperwork will be charged STARTING AT $125.00. Letters such as 504 letter, accommodation letters, form letters, and medications letters will be charged at a STARTING RATE OF $95.00.

 Prescriptions & Refills
Please allow
5 business days to completed the medication refill request. Our office does not refill medications on weekends or holidays. If you notice that you running out of medications and you do not have refills remaining, you must call and schedule an appointment as soon as possible, Please allow time (2-3 weeks) to schedule your follow-up appointments in order to guarantee medication refills. The providers will authorize phone requests for medication refills at their discretion, based on the patient's best interest and safety. If you recently saw the doctor and need a refill please contact your pharmacy and request a refill
  • Please note that if you need a same day refill there will be a $55.00 fee. If you need a rewrite of a contolled substance (including expired prescriptions) there will be a $35.00 fee.
  • Prescriptions for a stimulant medication (Schedule II controlled substance) cannot be called or faxed into the pharmacy and must be filled within 21 days. If you ae requiring a rewrite, the expired prescription can be reissued.
  • Medications will only be refilled for current patient who maintain their reqularly scheduled appointments. Your refill will be denied if you have not been seen within the time frame recommended by your provider.
 Prior Authorizations
Prior authorizations are a courtesy service. While we do our very best to secure coverage for prescription medications, it is ultimately the patient's responsibiling to contact their insurnace company to determine which medications are covered or to request appeals for potential coverage.

 Treatment of Minors
*Please see addendum regarding treatment of minors of divorced parents or non-parent consent for additional policies related to these unique Minor 17 years of age or younger must be accompanied by a parent or legal quardian. Under no circumstances will medication changes be authorized without parent or legal guardian present.

 Appointments Rescheduled by the Clinic
At times our office may call to reschedule your appointment due to conflict with your provider's schedule. Providers at our clinic authorize their patients to see a Nurse Practitioner in this situation on the appointment date. If rescheduled, please check your medications to be sure you have enough to last until the date you return.

You are responsible for complying with your prescribe medication regimen and being adherent to appointments.  You Should not make any medication adjustments without consulting with your provider first. It's your responsibility to inform your provider of all medications you are taking, including over-the-counter medications and supplements. Medication adjustments cannot be made via phone or email and require a in clininc visit.



Your signature below indicates that you have read the office policies document in full, you understand all its provisions and you afree to abide by these policies throughout the course of your professional relationship with Benjamin's Behavioral Health Services and you may request a copy of this document at any time. You understand that the violation of any of these policies is grounds for termination of care.

 Patient Name:

Today's date: 

Patient Signature(or Legal Guarian, if a minor)

Relationship to patient (if applicable) 

Controlled Substance Policy

Please be advised that it is extremely hazardous to obtain prescription medication for controlled substance from numerous providers. Be aware that if you are prescribed a controlled substances the doctor may utilize the following resource to obtain a history of prescribed medications: requesting information form your past/ current treating physician, requesting information from current/previous pharmacy and conducing a DPS report.
*Please read thoroughly and initial next to each statment to indicate ypur understanding and afreement

  •   You acknowledge and agree to notify our clinic of any new medications as well as any medical conditions and/or adverse effects you experience from any of the medications that you consume. You shall untilize the prescribed dosage for the prescribed controlled substance. You will not share, sell, trade, exchange your prescription(s) for revenue, products, services, or in any possess use of this (these) prescription(s). You consent to keep and/or maintain this (these) prescription(s) in asecure and safe location
  •  Refills are exclusively provided as determined by your doctor. Absolutely no premature refills will be provided regardless of the circumstances (i.e., stolen, misplaced, mislaid, exceeding prescribed dosage, etcetera.)
  •  Schedule II: Controlled Substance prescriptions pertaining to stimulant drugs (Adderall, Ritalin, Concerta, Focalin, Dexedrine, Quillivant, Daytrana, ProCentra, etcetera.) cannot be telephoned or faxed to the clinic and Must be filled within 21 days (twenty-one days). In circumstance where a prescription for any stimulant medication is NOT filled within 21 days (twenty-one days), the expried prescription MUST be returned before a new prescription can be reissued. Please note there shall be a $55.00 (FIFTY-FIVE) charge to rewrite expired prescriptions.
  •  Changes and/or alterations in prescriptions shall ONLY be made in the course of clinic  visits and NEVER via telephone and/or during non-clinic hours.
  •  Urine drug screenings may be requested to track your consumption of prescribed controlled substances and to screen for the use of illegal sunstances. Refusal to consent to such testing shall subject you to a medication taper schedule and may result in the discontinuance of your prescription.
The patient's pharmacy, local authorities, and DEA will be notified if the treating physician belives the law has been violated in any manner by the patient

If it is determined that any of the above policies have been violated, all orders for these prescriptions will cease and the patient will be dismissed form the care of this office.

Acknowledgement of Controlled Substance Policy:

I have read and understand the policies regarding controlled substance prescriptions. I agree to the terms involved in the Controlled Substance Policy and have received a copy of this policy. I understand that if any of the above policies are violated or I choose not to adhere to these policies; I will be dismissed from this clinic and will not receive any refills from the treating physician.
Patient Name:


Today's Date:

Patient Signature (or Responsible Party, if a minor):

Relationship to patient (if applicable)



Patient Demographics


Patient's First Name   Patient's Middle Name  Patient's Last Name 


 Preferred Name (if applicable)
 Date of Birth


Parent/ Legal Guardian (If patient under 18) 
 Patient's Drivers License or other ID: 

Social Security Number:

 Marital Status  Preferred Contact (BBHS may use this method to contact you, and may leave a message if necessary):  Ethinicity Race 
 Home Address 
 Zip Code 


 Primary Phone Number
 Secondary Phone Number



 Employer Name: 
Work Phone Number:  


 Preferred Language  
 U.S Military veteran:   

How did you hear of our services?     
Name of Referral Source:

 Emergency Contact Name: 
 Relationship to patient

 Primary Phone Number:



Home Address  City/ State    ZIP  

Does this person know that you are a patient at Benjamin's Behavioral? 

 Other Contacts:  Contact Name:  Relationship to Patient:  Phone Number:
 Legal Guardian      
 Primary Cargiver      
 Power of Attorney      
 Delegated Individual      
Other PRovider  


 Preferred Pharmacy Name 
 Phone Number 
 Fax Number

Zip Code 

what type of Insurance do you have?  

 Name of Insurance 
 Insurance Phone Number

 Insurance ID Number 
Insurance Group Number

Policy Holder Name (If different than patient) 
Policy Holder Date of Birth 
Policy Holder Social Sercurity Number 

 Relationship to Patient

By signing this form, I attest that all the statements I have made to all the questions are true and correct to the best of my knowledge and belief.

 Patitent Name 
 Date of Birth  

Name of Relationship to Patient (If different) 


Credit Card Authorization

I, , am authorizing Benjamin’s Behavioral Health Services to       
    (Print Patient’s Name or Guarantor’s Name)
Charge my credit card listed below if I fail to show for a scheduled/rescheduled appointment, or do not give notification of my inability to attend a scheduled appointment in advance. 

Please remember that all follow-up appointments need to be cancelled at least 48 business hours in advance and all new Patients appointments need to be cancelled at least 48 business hours in advance.

Please note, reminder calls/texts/email are a courtesy. You are responsible for your appointment whether your reminder was received or not.

I further authorize Benjamin’s Behavioral Health Services to disclose information about my attendance/cancellation to my credit card company if I dispute a charge. 

 Card Type:        
 Card/ Debit Number:  
 CVV Sercurity Code:  Expiration Date: 
 Full Name on Card:
 Billing Address:

By signing below, I acknowledge that I read and understand the above terms and consent for Benjamin's Behavioral Health Services to place and keep the card information above in my patient file and that ny card will be charged the applicable fees in the event I do not show to my appointment and/or do not cancel at least 48 business hours before my scheduled appointment.                             


(Patient or financially responsible party named on card)
Patient Name :  Date of Birth


This form will be securely stored in your clinical file and may be updated upon request at any time. Please note, your credit card will not be charged unless the followng conditions apply: no-show for scheduled appointment, cancellation of an  new patient appointment less than 48 business hours in advance, cancellation of a follow up appointment less than 24 hours in advance, or participation in treatment (e.g. appointment or phone session) without payment rendered.


Notice Of Privacy Practices 

* This notice describe how health information about you may be used and disclosed and how you can get access to this in formation please review it carefully the privacy of health information is inportant to us.


We use and disclose health information about you for treatment, payment, and healthcare operations. For example: 
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you, or to family and friends you approve. 
Payment: We may use and disclose your health information to obtain payment for services we provide to you. 
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. You also have the right to request restrictions on disclosure of PHI (Personal Health Information), or alternative means of communication to ensure privacy. 
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. 
Required by Law: We may use or disclose your health information when we are required to do so by law or national security activities. 
 Abuse or Neglect: We may disclose your health information to appropriate authorities when we suspect abuse or neglect. 
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).


Access: You have the right to look at or get copies of your health information with limited exceptions. If you request copies, we will charge you a reasonable fee to locate and copy your information, and postage if you want the copies mailed to you. 
Amendment: You have the right to request that we amend your health information


If you want more information about our privacy practices or have questions or concerns, please contact us. 
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. 
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us with the U.S. Department of Health and Human Services. A Privacy/Contact Officer has been designated for this office. The Privacy Officer can be contacted by simply contacting the office and asking to speak to the Office Manager who serves as the Privacy Officer.


Informed Consent for Treatment

The risks, benefits side effects and alternatives of treatment as well as the consequences of noncompliance with treatment have been discussed with me and I have had the opportunity to ask questions. No promises have been made to me about the results of treatment. 

I understand that I need to provide accurate information about myself to my provider so that I will receive effective treatment. I also agree to play an active role in my treatment process. I understand that I may terminate treatment at any time. 

My signature below shows that I understand and agree with all of the above statements and give consent for evaluation and treatment. I have had the opportunity to ask questions about the treatment process. I also agree guarantee payment for the provider’s services. 

If the patient is a minor or has a legal guardian appointed by the court, the patient’s parent or legal guardian must sign this consent and provide the court documents that allow the guardian to seek treatment for patient.
If the patient is a minor, and lives with one the divorced parents, then the signed divorce document will need to be provided before patient is scheduled for an appointment.



By signing below, I acknowledge that I have received and agreed to this Notice of Privacy Practices and Consent for Treatment.
*If you do not sign this COnsent form agreeing to the provisions of the Notice of Privacy Practices and Consent for Treatment, We cannot treat you.

 Patient Name: 
Date of Birth:  

Today's Date 

Patient Signature(or Legal Guarian, if a minor)

Relationship to patient (if applicable)

Thank you for your cooperation and welcome to our practice!