Intake Form English

  • Intake Form

    Please complete this form to request services for you or someone else at Family Service of El Paso.
  • Date*
     - -

  • 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

  • Name of 'La Fe' Case Manager that is assisting you

  • 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?*
  • Have you been approved by la Fe to receive financial assistance to pay for your counseling services?*
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  • Removal Date*
     - -
  • What type of services are you requesting?*

  • Please be aware that your spouse/partner may be contacted to consent of being part of this application.

  • Format: (000) 000-0000.
  • Spouse/Partner Date of Birth*
     - -
  • Are you legally married?*

  • 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?*
  • Is the person who is going to receive services under the age of 18?*
  • Has the child been named under custody agreement or court order?*

  • 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?*
  • 0/100

  • Client Information

  • Pronouns
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 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.

  • Emergency Contact Information

  • Format: (000) 000-0000.

  • 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]*
  • Please list your available times [choose multiple]*
  • Preferred Session Format*

  • Health Insurance Information

  • Format: (000) 000-0000.
    • *If TriCare was selected above, please fill out additional information below: 

    • If TriCare was selected above, please fill out the additional information below.

      If 'Other' insurance was selected, enter 'N/A'

       

    • (TRICARE ONLY) Military enlisted date
       - -
    • Format: (000) 000-0000.
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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.

    • Proof of Income

      Most recent 3 paycheck stubs of the 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  $25 missed appointment fee. Last Minute Cancellations and Missed Appointments: We do require a 48-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 48-hour or on same-day notice or appointments not kept will be subject to a $25.00 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,

  • 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.  

  • 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.
  • 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*********

  • REACH Program Demographic Data Notice

  • 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

  • Sign & Click the 'Submit' Button

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