Client Information
Completed By:
Required
Preferred Name (How you would like us to refer to you)
Client Legal First Name
Required
Client Legal Middle Name
Client Legal Last Name
Required
Which of our clinics will you be coming to?:
Client Sex Assigned at Birth
Date of Birth (mm/dd/yyyy)
Required
Social Security Number
Landline Phone
Cell Phone
E-mail Address
Required
Cell Phone Provider
Address (Number, Street, apt#)
City
State
County
ZipCode
Emergency Contact Name
Relationship
Emergency Contact Phone
Do you need a formal assessment to be sent to DCFS or another agency/provider?
Client Background Information
Who referred you to Wasatch Behavioral Health?
Employment Status:
Current Living Arrangements:
Race: (check one)
If Other Race
Please Specify:
Hispanic Origin: (check one)
If Other Please Specify
Who is your primary care doctor?
Are you currently pregnant?
When was your last visit with your doctor?
Do you think of yourself as:
What is your current gender indentity?
Years of Education Completed (GED=12)
Did the client attend school or an educational program in the last 3 months?
Has the client ever taken special education or resource classes or been diagnosed with a learning disability?
Marital Status: (check one)
Please list any social, cultural, or religious groups that you identify with.
Does the client have an open case with DCFS?
SSI/SSDI Eligible:
How many times have you been arrested in the last 30 days?
Are you currently required to attend treatment by a criminal court (includes plea in abeyance agreements, diversion programs or condition of probation or parole)?
Tobacco Use?
Number of times in substance use treatment (including detox)
How many times have you attended self-help groups in the past 30 days?
Military Status: (check one)
Language for Treatment:
Other Language:
Please check any of the following symptoms that you have experienced to a significant degree in the last month:
Notice of Privacy Practices, Consent, and Authorization
Authorization
I authorize Wasatch Behavioral Health Special Services District (WBH) to provide treatment to me and/or my minor child or a child for whom I have legal custody. I authorize my insurance company or other third-party funding sources to send payment directly to WBH. If my insurance company sends me a check for services that I have received at WBH, I will forward the check and explanation of benefits (EOB) to WBH. I request that any available grant funding be applied to my balance to cover services not covered by my insurance or other funding sources. I agree to pay any fees that are not paid by my insurance or any available grants. Any unpaid balance may be turned over for collection after 90 days; and, I agree to pay all costs of collection, including but not limited to reasonable attorney’s fees. I understand WBH may charge interest on balances over 90 days.
Informed Consent for Assessment and/or Treatment
I understand that my treatment at Wasatch Behavioral Health may be provided by licensed clinical staff or clinical staff being supervised by licensed clinical staff (such as staff working toward their license, students/interns, or trained but not licensed staff). I understand that staff who aren’t licensed (such as staff working toward their license, students/interns, or trained but not licensed staff) are working under the supervision of a licensed clinical staff. I authorize Wasatch Behavioral Health to provide treatment to me via telehealth.
Consent to Leave Messages
The health Insurance Portability and Accountability Act of 1996 (HIPAA) requires Wasatch Behavioral Health to have your written authorization to leave messages on your answering machine/service, voicemail, or with family members and friends. This allows us to confirm appointments or to leave other messages relating to your care. Specific information regarding your treatment will not be disclosed. Allowing us to contact you in this manner helps our staff to better serve you and increases our ability to serve the community.
I authorize Wasatch behavioral health to contact me through and leave messages on any land line phone, cell phone, email address and/or text messaging number that I have provided.
Consent to Receive Telehealth Services
In an effort to provide services to clients who are unable to travel to our clinics for face-to-face meetings, Wasatch Behavioral Health offers several of its services remotely via two-way videoconferencing software (such as Zoom, Jitsi, or other proprietary applications - collectively referred to as "Telehealth"). Although Wasatch Behavioral Health takes efforts to ensure the security of the systems used, as with the use of any electronic communication system like text messaging or email, it is possible that this communication could be accessed by others or overheard by others in the client's dwelling at the time of the appointment.
If I choose to access telehealth services, I authorize Wasatch Behavioral Health to provide those services to me, with an understanding of the potential limitations to the security of my information.
Photographic Identification – Clinical Consultation/Supervision
I consent to have mine, or my minor child’s or a child for whom I have legal custody of, picture taken for identification purposes only. I understand that Wasatch Behavioral Health retains the ownership rights to this/these photographs.
I understand that Wasatch Behavioral Health Provides consultation/supervision for their staff. I agree to have mine, or my minor child’s or a minor child for whom I have legal custody of, treatment session(s) video/audio recorded for staff consultation/supervision. I understand that these recordings will be maintained in a secure location and destroyed when no longer needed. I understand that I may revoke this consent at any time without consequences.
Information Received
Notice of Privacy Practices:
click here to access Wasatch Behavioral Health’s Notice of Privacy Practices I understand that I may request a hard copy of the Wasatch Behavioral Health Notice of Privacy Practices at my clinic at any time and that a copy will be provided to me within five days free of charge. I acknowledge that I have received the Wasatch Behavioral Health’s Notice of Privacy Practices.
Medicaid Member Handbook:
Click here to access a copy of the Medicaid Member Handbook I understand that I may request a hard copy of the Medicaid Member Handbook at my clinic at any time and that a copy will be provided to me within five days free of charge. I acknowledge that I have received the Medicaid Member Handbook, and that I am aware of where in the handbook I can find information about (1) transportation, (2) services from providers (3) emergency services, (4) complaints/grievances, (5) appeals, and (6) rights and responsibilities. I also acknowledge that any client of Wasatch Behavioral Health has the right to discuss concerns or file a complaint/grievance with any staff member.
I acknowledge that I have read and understand this notice of privacy practices, consent and authorization, and agree to the elements listed therein.
Please click or tap on the "Choose File" button below to upload an image of the front and back of the client's driver's license or state I.D. card, the front of the medicaid card, the front and back of any other insurance card, as well as any adoption, custody, guardianship, and/or power of attorney paperwork.
You will need to press upload after selecting each image/file. If the file upload finishes, the file name will appear in the box below.
Type your name below to sign:
Signed by:
Date Signed: