IntakePpw

Client Intake Form

Please call reception with any questions at (801)990-4300 to make sure services at Aspen Ridge Counseling are what you are needing.
Today's Date

Month Day Year
Date
Client Legal Name *

First Name Middle Name Last Name
Preferred Name
If different from legal name
Reason for Seeking Treatment *

Client Demographic Information
Client Birth Date *

Month Day Year
Age
Legal Gender *
Client Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Is Client Physical Address the same as the Mailing Address? *
Client Physical Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Social Security Number
111-11-1111
Cell Phone Number *
Please enter the cell # used for text reminders
Email *
*Invoices will be sent to this e-mail*
Referral Source *
How did you hear about Aspen Ridge? *
Hispanic or Latino Origin? *
Race *
Marital Status *
Completed years of Education *
example (12 years, GED, Nursery/Pre-K, Kindergarten etc)
Attended school anytime in the last three months? *
Previous Mental Health Treatment of any kind? *
Previous Mental Health Treatment at Aspen Ridge Counseling? *
Previous Mental Health Treatment at Utah State Hospital? *
Employment Status *
Living Arrangement *
Gross Monthly Household Income *
Total number of family members who live at home *
Smoking Status *
Language *
Number of Arrests in last 30 days *
Current legal involvement? *
Description of Legal Involvement *
Please indicate if counseling was recommended or required by the Court System.
Does the Client have Medicaid as their insurance (either primary or secondary)? *

YES NO

Responsible Party Information
The Responsible Party is the person signing the intake paperwork. Typically this is either the Client or the Parent/Guardian of a Client.
The Responsible Party is: *

The Client (age 18 & up with no legal guardian) The Parent The Client's Legal Guardian
Responsible Party *

First Name Last Name
Responsible Party Birth Date *

Month Day Year
The Responsible Party resides at the same address as the Client.

Yes No
Responsible Party Phone Number *
Please enter a valid phone number.
Responsible Party Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Notes *
Any additional contact Information- Other parent/guardian, any notes re: custody etc.

Emergency Contact Information
Emergency Contact Name *

First Name Last Name
Relationship to Client *
Emergency Contact Phone Number 1 *
Main phone #
Emergency Contact Phone Number 2
Additional contact #
Emergency Contact Notes
Any additional information?/Contact info etc*

Medicaid Paperwork
I acknowledge that I have received a Medicaid Member Handbook and Provider Directory ( either in the mail or from my provider *link above). I understand that the purpose of this book is to insure I have information about my benefits, rights and
responsibilities. The handbook also provides information on how to receive covered services, access to emergency services, transportation and how to choose a provider. The handbook also addresses procedures for filing grievances
and appeals.
I also understand that if I have been treated unfairly or discriminated against for any reason, I may file a complaint by contacting Optum Health at 1-877-370-8593
Client or Parent/Guardian Signature *

Clear
*

Adult Outcome Questionnaire *Clients 18 and up*
INSTRUCTIONS: Looking back over the last week, including today, help
us understand how you have been feeling. Read each item carefully and select
the category which best describes your current situation. For this questionnaire, work
is defined as employment, school, housework, volunteer work, and so forth.
I have trouble falling asleep or staying asleep. *
I feel no interest in things. *
I feel stressed at work, school or other daily activities. *
4. I blame myself for things. *
5. I am satisfied with my life. *
6. I feel irritated. *
7. I have thoughts of ending my life. *
8. I feel weak. *
9. I find my work/school or other daily activities satisfying. *
10. I feel fearful. *
11. I use alcohol or a drug to get going in the morning. *
12. I feel worthless. *
13. I am concerned about family troubles. *
14. I feel lonely. *
15. I have frequent arguments. *
16. I have difficulty concentrating. *
17. I feel hopeless about the future. *
18. I am a happy person. *
19. Disturbing thoughts come into my mind that I cannot get rid of. *
20. People criticize my drinking (or drug use). (If not applicable, ……mark "never".) *
21. I have an upset stomach. *
22. I am not working/studying as well as I used to. *
23. I have trouble getting along with friends and close acquaintances. *
24. I have trouble at work/school or other daily activities because of drinking or drug use. (If not applicable, mark "never".) *
25. I feel that something bad is going to happen. *
26. I feel nervous. *
27. I feel that I am not doing well at work/school or in other dailyactivities. *
28. I feel something is wrong with my mind. *
29. I feel blue. *
30. I am satisfied with my relationships with others. *

Client History
Current Medications *
Allergies *
Chronic Illnesses *
Communicable Diseases *
Other Important Information:

Insurance Information
Please complete Primary Insurance Information (& Secondary if you have this). If not using insurance (example, Self-pay, CVR, Voc Rehab etc), note this in Primary Insurance Box
PRIMARY INSURANCE OR PAYMENT INFORMATION *
SECONDARY INSURANCE OR PAYMENT INFORMATION
Upload Copy of Insurance Card(s), or other payment-related docs *You can also send any relevant information to info@aspenridgecounselingcenter.com

Important Documents to Review
I'm aware that Crisis information is available to me *See Informed Consent* *

Yes
I understand that smoking is prohibited at all Aspen Ridge Counseling offices. *

Yes
By signing and checking above boxes, I agree that I've read the Informed Consent, HIPAA guidelines and LC/NS policy. I also am advising that all information completed in this packet is accurate and will update Aspen Ridge Counseling with any changes that may impact services.
Client (or parent/guardian signature) *

Clear
*
Should be Empty:

Client Intake Form