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  • Client Intake Form

    Client Intake Form

    Please call reception with any questions at: (801) 990-4300 to determine if Aspen Ridge Counseling provides the services you need.
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    • Client Demographic Information 
    • 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.  

    • Emergency Contact Information 
    • Medicaid Paperwork 

    • I acknowledge that I have received a Medicaid Member Handbook (English | Spanish) 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

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    • 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.

    • Youth Outcome Questionnaire- Parent/Guardian Version *Clients Under 18*  
    • DIRECTIONS: Read each statement carefully.  Decide how true this statement is during the past 7 days for your child.  Select the choice that most acurately describes the past week.

    • Client History 
    • 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

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  • Medical Coordination of Care

    Medical Coordination of Care

  • 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.

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    • Important Documents to Review 
    • 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.

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