Intake Form
Please complete this form to request services for you or someone else at Family Service of El Paso.
Date
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Month
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Day
Year
Date
Contact Email Address
example@example.com
How did you find out about Family Service of El Paso?
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Google / Internet search
Someone personally recommended
Doctor or another profesional referral
Referred by LaFe Clinic
Referred by Project C.H.A.M.P.S
Referred by the Juvenile Probation Department
Referred by REACH program
Referred by CPS
Referred for CANS Assessment
Name of 'La Fe' professional that referred you
Please upload a copy of your referral on the 'Additional Documents Section' of this form.
First Name - Last Name, Title
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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 approval letter from LaFe
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Name of the doctor who referred you
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Name of "other" professional who recommended you
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PID#
*
Removal Date
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-
Month
-
Day
Year
Date
What type of services are you requesting?
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Individual
Family
Couples/Marriage
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
Are you the Parent or Guardian of this minor/ underage person?
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Yes
No
What is your relationship to the person requesting services?
Parent/Guardian Name:
First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the main reason you are seeking services?
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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.
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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
Gender Identity
*
Please Select
Male
Female
Transgender Male/Trans Man/FTM
Transgender Female/Trans Woman/MTF
Other
Choose Not to Disclose
Administrative Sex
*
Please Select
Male
Female
Unknown
Sexual Orientation
*
Please Select
Heterosexual/Straight
Lesbian, gay, homosexual
Bisexual
Other
Unknown
Choose Not to Disclose
Race/Ethnic
*
Please Select
American Indian or Alaskan Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian or Other Pacific Islander
White
Choose Not to Disclose
Language Preference
*
Please Select
English
Spanish
Other (please specify below)
Type Language preference (Other than English or Spanish)
Marital Status
*
Please Select
Single
Married
Cohabitating [Living Together]
Widow/er
Other
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
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Contact and appointment Reminder Preference
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Text
Phone Call
Email
Are you currently under psychiatric care?
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Yes
No
Currently seeking services
I don't know
Psychiatrist Name
First & Las Name
Diagnosis(es)
Provide Name of Diagnosis
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]
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Monday
Tuesday
Wednesday
Thursday
Friday
Any Day
Please list your available times [choose multiple]
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8 a,m.- 12 p.m.
12 p.m. - 5 p.m.
5 p.m - 8 p.m.
Any Time
Preferred Session Format
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In Person
Telehealth
Either
Health Insurance Information
Select your current health care type
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Employee Assistance Program [EAP]
Medicaid
Medicare
Chips
Private Health Insurance
None
EAP Name
*
EAP Authorization Number
*
EAP Phone Number
*
-
Area Code
Phone Number
Name of Private Health Insurance
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Aetna
Amerigroup
Amerigroup Medicare
Blue Cross Blue Shield
Cigna
CompPsych
Concern EAP
El Paso First
Humana
Interface EAP
MEDICARE
Medicaid of Tx
Molina
Tricare/UHC
Optum Psych
Sun City EAP
Superior
Value Options
Other
EAP Only
If you chose 'Other' please enter name below
Name of Insured
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First Name
Last Name
Date of Birth of Insured
*
-
Month
-
Day
Year
Date
Medicaid Number
Social Security Number of Insured
only number, no dashes
Member ID
*
Phone Number
-
Area Code
Phone Number
Upload picture of FRONT of your Insurance card
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Upload picture of BACK 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.
What is your gross household/family income?
*
If you have no income type $0
What is your gross household/family income frequency?
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Annual
Monthly
Weekly
Bi-weekly
Semi-monthly
Select based on the amount you provided in the previous question
Are you currently employed?
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Yes
No
Self-employed
Employer Name
If not employed type N/A
Do you get any supplemental income?
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None
Social Security
Unemployment Benefits
Child Support Assistance
Family Allowance
Proof of Income
Most recent 2 paycheck stubs of the head of household.
Upload Here
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Must be under Household Name. This could be your most recent bank statement, a pay stub, etc.
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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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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
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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********
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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.
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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)
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Signature
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