Intake Registration Form (Treyway Multi Treatment Services Clients Only)

EMERGENCY CONTACT FORM
Client Name*

First NameLast Name
Purpose of the Emergency Contact Form:

This form ensures we have the necessary information to contact your trusted individuals for emergencies only.
Is the client 18 years or older at the time of appointment?*

YesNo
Emergency Contacts
Name of Emergency Contact
Relationship to Client
Phone Number
Name of Emergency Contact #2
Relationship to Client
Phone Number
Address
Acknowledgment and Consent:

I acknowledge that I have provided accurate and up-to-date emergency contact information on this form. I understand that the individuals and/or Primary Care Physician listed will only be contacted in the event of an emergency or as required to ensure my safety and continuity of care. I also understand that it is my responsibility to notify Pathways Behavioral Health Group of any changes to the information provided.
Client Signature*

Clear
MonthDayYear
Date

ADVANCED DIRECTIVE FOR MENTAL HEALTH SERVICES
Client Name*

First NameLast Name
Please mark your preference with a check regarding Advance Directive for Mental Health Services*

I am not interested in more information at this time.Please provide me with an Advance Directive for Mental Health Services form to be completed.
Client Signature*

Clear
MonthDayYear
Date

AUTHORIZATION TO DISCLOSE SUBSTANCE USE TREATMENT INFORMATION FOR COORDINATION OF CARE
Client Name*

First NameLast Name
Date of Birth*
Street Address*
City*
State*
Zip Code*
Cell Phone Number
Home Phone Number
Medical Assistance Number*
Enter Social Security Number if you don't know your MA Number
If you want to identify the kind or amount of information that you are authorizing for disclosure, you may do so here:
Section 5 (OPTIONAL): I authorize the Maryland Medicaid Program, Carelon Behavioral Health, my MCO, and my substance use disorder treatment provider(s) to disclose all substance use disorder treatment records to the additional health care provider(s) specified below for treatment purposes

I do not want to have my SUD treatment records shared with additional providers.
Provider Name
Provider Address
If you want to identify the kind or amount of information that you are authorizing for disclosure, you may do so here:
Patient Signature*

Clear
MonthDayYear
Date