Intake Form
Please complete this form to request services for you or someone else at Family Service of El Paso.
Date
*
-
Month
-
Day
Year
Date
Contact Email Address
example@example.com
Once the intake is complete and submitted, a confirmation email will be sent to this email address to assure that your intake form has been received by our staff. Please verify before submitting
How did you find out about Family Service of El Paso?
*
Please Select
Google / Internet search
Someone personally recommended
Doctor or another profesional referral
Referred by LaFe Clinic
Referred by La Fe CARE [Ryan White Program]
Referred by Project C.H.A.M.P.S
Referred by the Juvenile Probation Department
Referred by REACH program
Referred by Aliviane
Referred by CPS
Referred for CANS Assessment
Referred by Advocacy Center for the Children of El Paso
Referred by Goodwill EAP
Name of Goodwill Supervisor
*
First Name
Last Name
Goodwill Store # or Location
*
Name of 'La Fe' Case Manager that is assisting you
Name
*
First Name
Last Name
Do you authorize Family Service of El Paso to disclose appointment dates, times and attendance information with La Fe staff prior to your first session?
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Yes
No
Do you have health insurance to cover your counseling services?
*
Please Select
Yes
No
Have you been approved by la Fe to receive financial assistance to pay for your counseling services?
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Yes, I was approved
I was not approved
Application still in process
None of the above
Please upload your payment letter from LaFe
*
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Name of the doctor who referred you
*
Name of "other" professional who recommended you
*
PID#
*
Removal Date
*
-
Month
-
Day
Year
Date
Name of the Family Advocate that referred you at Advocacy Center for the Children of El Paso?
First Name
Last Name
What type of services are you requesting?
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Individual
Family
Couples/Marriage
Please be aware that your spouse/partner may be contacted to consent of being part of this application.
Spouse/Partner Name
*
First Name
Last Name
Spouse/Partner Phone Number
*
Please enter a valid phone number.
Do you consent for your spouse to modify scheduling matters?
*
Please Select
Yes
No
Spouse/Partner Date of Birth
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-
Month
-
Day
Year
Date
Are you legally married?
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Yes
No
We recommend that you discuss the matter of therapy with your spouse/partner subsequently to this application.
If we contact, will the spouse be aware of this request for services?
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Yes
No
Please list the names and date of birth of each of the family members that will attend the sessions:
*
Are you completing this form on behalf of someone else?
*
Please Select
Yes
No, completing for myself
Preparer Name (if completing for someone else)
*
First Name
Last Name
Is the person who is going to receive services under the age of 18?
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Yes
No
Has the child been named under custody agreement or court order?
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Yes
No
Please be advised that you will be required to provide court paperwork prior to assigning the child for services
You can upload the documentation on the 'Additional Documents' section of this form. Be mindful that if you do not upload the documents, you will not be able to proceed with the submission of the form.
Are you the Parent or Guardian of this minor/ underage person?
*
Yes
No
What is your relationship to the person requesting services?
Parent/Guardian Name:
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the main reason you are seeking services?
*
Please Select
Battling addiction
Marriage/Relationship Issues
Anger management
Depression
Anxiety / Stress
Trauma
Grief / Loss
Phobia
Sleep issues
Obsessive Compulsive Disorder
Other
Please briefly explain the symptoms and/or problems you are experiencing.
*
Please provide additional information regarding your situation, that may be useful in your process.
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Client Information
Name
*
First Name
Last Name
Preferred Name
Pronouns
He/Him
She/Her
They
Smoker Status
*
Please Select
Smoker
Non Smoker
Have you received services from us before?
*
Please Select
Yes
No
Gender Identity
*
Please Select
Male
Female
Transgender Male/Trans Man/FTM
Transgender Female/Trans Woman/MTF
Other
Administrative Sex
*
Please Select
Male
Female
Sexual Orientation
*
Please Select
Heterosexual/Straight
Lesbian, gay, homosexual
Bisexual
Race
*
Please Select
American Indian or Alaskan Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian or Other Pacific Islander
White
Ethnicity
Please Select
Andalusian
Argentinean
Asturian
Belearic Islander
Bolivian
Canal Zone
Canarian
Castillan
Catalonian
Central American
Central American Indian
Chicano
Chilean
Colombian
Costa Rican
Criollo
Cuban
Dominican
Ecuadorian
Gallego
Gallego
Guatemalan
Hispanic or Latino
Honduran
La Raza
Mexican
Mexican American
Mexican American Indian
Mexicano
Nicaraguan
Not Hispanic or Latino
Panamanian
Praguayan
Peruvian
Puerto Rican
Salvadoran
South American
South American Indian
Spaniard
Spanish Basque
Uruguayan
Valencian
Venezuelan
Language Preference
*
Please Select
English
Spanish
Other (please specify below)
Type Language preference (Other than English or Spanish)
Religious Affiliation
*
Marital Status
*
Please Select
Unmarried
Married
Domestic Partner
Polygamist
Divorced
Widowed
Legally Separated
Interlocutory Decree
Annulled
Something Else
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
Do not include dashes "-"
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Alternate Phone Number
Contact and appointment Reminder Preference
*
Please Select
Text
Phone Call
Email
Are you currently under psychiatric care?
*
Please Select
Yes
No
Currently seeking services
I don't know
Psychiatrist Name
First & Las Name
Diagnosis(es)
Provide Name of Diagnosis
Client Household Demographic Information
Please provide household member information of the household where you reside. Please provide the information to the best of your ability.
Does your household have multiple members? [Not including yourself]
*
Please Select
Yes
No, I live by myself
Please list your household members
*
Emergency Contact Information
Would you like to provide an emergency contact? We will only contact this individual in case of an emergency only during your presence at our premises or during a telehealth session.
Please Select
Yes
No
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Relationship
Does this person know you are seeking services?
Please Select
Yes
No
Please authorize
*
I authorize the person listed above as my emergency contact, to be reached in case of anything considered an emergency by our staff; specifically during a session.
Session Appointment Preferences
Please select as many options possible so that we can accommodate you faster. Please be mindful that your application may be placed on a waiting list until we can match you to a therapist that fits your session appointment availability, therefore we ask that you consider multiple options.
Please list your available days [choose multiple]
*
Monday
Tuesday
Wednesday
Thursday
Friday
Any Day
Please list your available times [choose multiple]
*
8 a.m.- 9 a.m.
12 noon. - 1 p.m.
4 p.m. - 5 p.m.
9 a.m. - 10 a.m.
1 p.m. - 2 p.m.
5 p.m. - 6 p.m.
10 a.m. - 11 a.m.
2 p.m. - 3 p.m.
6 p.m. - 7 p.m.
11 a.m. - 12 noon
3 p.m. - 4 p.m.
7 p.m. - 8 p.m.
Preferred Session Format
*
In Person
Telehealth
Either
Health Insurance Information
Select your current health care type
*
Please Select
Employee Assistance Program [EAP]
Medicaid
Medicare
Chip
Private Health Insurance
None
EAP Name
*
EAP Authorization Number
*
EAP Phone Number
*
Name of Private Health Insurance
*
Please Select
Aetna
Amerigroup
Amerigroup Medicare
Blue Cross Blue Shield
Cigna
CompPsych
Concern EAP
El Paso First
Humana
Interface EAP
MEDICARE
Medicaid of Tx
Molina
Tricare
Optum Psych
Sun City EAP
Superior
UHC
Value Options
Other
If you chose 'Other' please enter name below
*
Medicaid Number
Social Security Number of Insured
only number, no dashes
Member ID
*
Insurance Company Phone Number
Upload picture of FRONT of your Insurance card
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Financial Information
At Family Service of El Paso, our desire is that every individual and/or family in the El Paso community would have access to mental healthcare services. Cost and affordability are often an obstacle even when health insurance is on hand. In order to provide you with the necessary services you and your family deserve, we would like to assess your financial condition to accommodate you with a plan that best fits you. Please answer each question thoroughly. We ask that you prepare any proof necessary that would help us determine a reasonable fee based on your financial situation. If necessary, we can provide additional assistance if you complete the SLIDING FEE SCALE APPLICATION. A link to the application will be provided to you at the completion of this form.
What is your gross Yearly household/family income?
*
Please Select
$0-$5,000
$5001-$10,000
$10,001-$15,000
$15,001-$30,000
$31,000-$50,000
$50,001-$70,000
$71,000-$99,999
$100,000 and above
What is your gross household/family income frequency?
*
Please Select
Annual
Monthly
Weekly
Bi-weekly
Semi-monthly
Select based on the amount you provided in the previous question
Employment
*
Please Select
Full Time Employed
Part Time Employed
Self Employed
Contract, Perdiem
Full Time Student
Part Time Student
On Active Military Duty
Retired
Leave of Absence
Temporarily Unemployed
Unemployed
Something Else
Employer Name
If not employed type N/A
Do you get any supplemental income?
*
Please Select
None
Social Security
Unemployment Benefits
Child Support Assistance
Family Allowance
Proof of Income
Most recent 3 paycheck stubs of the total household income.
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Must be total household income.
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Additional Documentation
Please upload any additional documents (e.g., referrals) that may be deemed necessary to review during your intake process. Custody agreements are required if the services will be rendered for someone underage and the parents are separated.
Please be mindful that any documentation not uploaded such as Health Insurance Cards, Proof of Income, or any other documentation deemed important will delay the process of providing you services. If you are having difficulty uploading documents on this intake form, please call our office immediately.
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Appointment Policy
At Family Service of El Paso, we pride ourselves in offering you personalized care and reserve appointment times to accommodate your needs. Late arrivals, missed appointments or cancelled appointments without sufficient notice, create a gap in our clinician’s schedule. These are appointments that could have been utilized to offer care to another client. Late Arrivals: If a client is more than 15 minutes late for an appointment (in-person or telehealth), the appointment may need to be rescheduled. This is to ensure that the patients who arrive (or connect) on time do not wait longer than necessary to see the clinician. We cannot compromise on the quality and timely care provided to our other clients. If a client presents to the office (or connects) 15 minutes late for a scheduled appointment with our providers, the patient will be asked to reschedule their appointment and the appointment will be considered as missed and is subject to a $20 missed appointment fee. Last Minute Cancellations and Missed Appointments: We do require a 24-hour notice on all cancellations. As a courtesy to our clients, we attempt to confirm all appointments. We do recognize that situations arise that are out of your control; however, it is imperative that you contact our office immediately to notify us of your cancellation in a timely manner. Appointments cancelled with less than a 24-hour or on same-day notice or appointments not kept will be subject to a $20.00 fee. We ask for your consideration and cooperation in scheduling your next appointment. Please understand that we are partners in your mental health, and we are committed to offering you appropriate care when you need it,
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DISCLAIMER FOR INSURANCE BENEFITS
A 'quote' of benefits does not guarantee payment. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service." If the insurance does not pay, you (the client receiving services/&/or head of household responsible for the payment will be responsible for their copay.
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Informed Consent for Mental Health Services
Please read and acknowledge by signing below.
This notification describes how your medical information can be utilized and shared/released and how you can access such information. Read carefully.
I, person whose signature is at the bottom of this document, hereby consent to engaging in telemental health and/or in-person therapy with my provider at Family Service of El Paso as part of my psychotherapy or the psychotherapy of the person for whom I am consenting. I understand that “telemental health” and “in-person therapy” include the practice of health care delivery, diagnosis, consultation, treatment, transfer of mental health data, and education using interactive audio, video, or data communications. I understand that telemental health and in-person therapy also involve the communication of my medical/mental health information, both orally and visually. I understand the following with respect to telemental health and in-person: (1) I understand that I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment. (2) I understand that the laws that protect my medical and mental health information confidentiality apply the same to telemental health and in-person therapy. I also understand that the dissemination of any personally identifiable images or information from the telemental health and/or in-person therapy interaction to researchers or other entities shall not occur without my written consent. I understand that the information disclosed by me during the course of therapy is generally confidential. However, there are mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards self and/or an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I understand that my therapist may contact appropriate authorities in case of emergency. My assumed location will be the physical address that Family Service of El Paso has on my record, unless I orally/verbally provide a different location during a counseling session or another via of communication with my therapist or Family Service of El Paso office staff. (3) I understand that there are risks and consequences from telemental health and in-person therapy, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical or mental health information could be disrupted or distorted by technical failures. In addition, I understand that telemental health-based services and care may not be as complete as in-person services. I also understand that if my psychotherapist believes I would be better served by another form of psychotherapeutic services (e.g., in-person services, group therapy), I will be referred to a psychotherapist who can provide such services in my area if Family Service of El Paso does not offer them. (4) I understand that I may benefit from telemental health and/or in-person therapy, but that results cannot be guaranteed or assured. I understand that there are potential risks and benefits associated with any form of psychotherapy and that despite my efforts and the efforts of my psychotherapist, my condition may not improve. (5) I understand that I have a right to access my medical and mental health information and copies of medical records in accordance with Texas law. (6) I understand that an additional charge may apply if I request my mental health records to be released/shared to/with myself or another entity. This disclosure will only be completed upon my written signed authorization/consent. An additional Release of Information Authorization form will be provided for my review in that case. (7) I understand that Family Service of El Paso administrative staff has the right to utilize my information to check my benefits with another entity or entities, if applicable. The purpose of this disclosure regarding health care insurance is to develop a coverage plan for my counseling sessions.I have read and understand the information provided above. I have addressed my questions with Family Service of El Paso office staff and they have been answered to my satisfaction.
Please acknowledge below
*
I acknowledge to the Informed Consent for Mental Health Services
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Health Information Exchange: Your PHI may be used and disclosed with other health careproviders or other health care entities for treatment, payment, public health, and health care operations purposes, as permitted by law, through the Paso Del Norte Health Information Exchange (PHIX). For example, information about your past medical care and current medical conditions and medications can be available to other primary care physicians or hospitals, if they participate in PHIX. Exchange of health information can provide faster access, better coordination of care and assist providers and public health officials in making more informed treatment decisions. You may opt out of PHIX and prevent providers from being able to search for your information through the exchange.You may opt out and prevent your medical information from being searched through PHIX by completing and submitting an Opt-Out Form to the registrar. ******Please acknowledge below********
*
I have read and understand the Health Information Exchange notice
I have read and understand the Health Information Exchange notice and wish to OPT OUT
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REACH Program Demographic Data Notice
The REACH (Resilience, Education, Action, Commitment, and Humanity) program will be obtaining deidentified secondary data from your satisfaction of service and demographic data for evaluation research purpose.
*
I have read and understand the REACH Data Notice
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Health Information Exchange OPT OUT
By selecting that you 'wish to OPT out of the Health Information Exchange' on the previous page, you are opting out and will prevent your medical information from being searched through PHIX. In order to validate this request, you must complete and submit the Opt-Out Form [Please click the link below]. You can 1) download & print 2) complete 3) sign 4) return completed form to: Family Service of El Paso administration office via mail or in person to 6040Surety Drive, El Paso Tx, 79924. Please call 915-781-0276 Extension 113 if you have any questions regarding this Out Out form
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Sign & Click the 'Submit' Button
Legal Guardian Signature (if under age 18)
Signature
*
Submit
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