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  • Client Intake Form

    Client Intake Form

    Please call reception with any questions at: (801) 990-4300.
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    • Client Demographic Information 
    • 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.  

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    • Emergency Contact Information 
    • 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

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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.

    • 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. 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.

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  • Educational Coordination of Care

    Educational Coordination of Care

  • 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. 

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    • Important Documents to Review 
    • 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.

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