IntakePpw

Client Intake Form

Please call reception with any questions at: (801) 990-4300.
Today's Date

MonthDayYear
Date
Aspen Ridge Client Status*
Client Legal Name*

First NameMiddle NameLast Name
Preferred Name
If different from legal name
Reason for Seeking Treatment*

Client Demographic Information
Client Birth Date*

MonthDayYear
Age
Legal Gender*
Client Mailing Address*

Street Address

Street Address Line 2

CityState / Province

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
111-11-1111
Cell Phone Number*
Email*
*Invoices & appointment reminders will be sent to this e-mail*
Opt in for Aspen Ridge Counseling Newsletter/Marketing Emails
Referral Source*
How did you hear about Aspen Ridge?*
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?*
Is Client a Veteran?*
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)?*

YESNO

Responsible Party Information
The Responsible Party is the person signing the intake paperwork. This must be either the Client (if 18 years or older) or the Parent/Legal Guardian of the Client.
The Responsible Party is:*

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

First NameLast Name
Responsible Party Birth Date*

MonthDayYear
Responsible Party Social Security Number
Photo ID of Responsible Party*

Can be Driver's License, State ID, Passport, Etc.
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The Responsible Party resides at the same address as the Client.

YesNo
Responsible Party Phone Number*
Please enter a valid phone number.
Responsible Party Mailing Address*

Street Address

Street Address Line 2

CityState / 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 NameLast 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 (Salt Lake County | Tooele County) and Provider Directory (either in the mail or from my provider *link above). I understand that the purpose of this book is to ensure 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*

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Adult Outcome Questionnaire *Clients 18 and Older*
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.
1. I have trouble falling asleep or staying asleep.*
2. I feel no interest in things.*
3. 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 PAYER INFORMATION*
SECONDARY INSURANCE OR PAYER INFORMATION
Take a photo of insurance cards and any other necessary documentation here:
Upload insurance cards and any other necessary documentation here:

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Medical Coordination of Care
Client Name*

First NameLast Name
At Aspen Ridge Counseling, we feel it is important to work with your Primary Care Physician to provide the best care possible. Please complete as much of this information as you are able to allow your Therapist to coordinate with your Primary Care Physician. The information to be shared from this Release of Information is 1) Client Therapist Information 2) Treatment Attendance 3) Current Progress in Treatment. If more information is needed, Client or Responsible Party can complete a more in-depth release of information with the provider or HERE.

Unless Client or Responsible Party rescinds this release of information earlier, this release of information will remain active for 1 year from the date signed. You can update or rescind this release at any time by contacting our office.
Primary Care Physician Information
Please select one of the following and sign:*

By checking this box and signing this form, I agree to have Aspen Ridge Counseling contact the above provider and share necessary information to coordinate care related to my treatment needs.I do not currently have a regular Primary Care Physician.I wish to decline coordination of care at this time.
Responsible Party Signature*

Clear

Educational Coordination of Care
Client Name*

First NameLast Name
At Aspen Ridge Counseling, we feel it is beneficial to work with a team in order to provide the best care possible. This release of information is mainly for those clients with school-related issues or those working closely with another provider at the school. Please complete as much of this information as you are able to allow the Client's Therapist to coordinate care with Client's school contacts.

The information to be shared with this form is 1) Client Therapist and Contact Information 2) Current Treatment Attendance 3) Current Progress in Treatment.

You can rescind this release of information at any time by contacting our office.
Name of School*
Current Grade Level in or last completed*
for example, if it's March- sophomore, if it's July and Jr year has not started, still mark sophomore
Any Further Information
Names of Teachers, School Counselors, or School Social Workers working with Client; Any contact information for this school
Please select one of the following and sign:*

By checking this box and signing this form, I agree to have Aspen Ridge Counseling contact the school contacts in order to coordinate care related to my treatment needs.I wish to decline coordination of care at this time.
Responsible Party Signature*

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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 acknowledge that I've read and agree to all terms within the Informed Consent, HIPAA guidelines and LC/NS policy. I also am advising that all information completed in this packet is accurate to the best of my knowledge and I will update Aspen Ridge Counseling with any changes that may impact services.
Client (or parent/guardian signature)*

Clear
Should be Empty:

Client Intake Form

Medical Coordination of Care

Educational Coordination of Care