Client Intake and Consent Form
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CLIENT INFORMATION
Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender Identity
Please Select
Male
Female
Non-binary/Genderqueer/Genderfluid
Transgender
Two-Spirit
Agender
Prefer to Self-Describe
Prefer Not to Disclose
Other
Tribal Affiliation(s): [If appropriate]
Contact Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text
Mail
Emergency Contact
Name
*
Relationship
*
Phone
*
Please enter a valid phone number.
INSURANCE INFORMATION
Type of Insurance
*
Medicaid
Turquoise Care Medicaid
Private
Self-pay
Other
Please note: We are not able to accept Medicare at this time. If you have Medicaid as your secondary insurance, please select Medicaid or Turquoise Care Medicaid, please make the appropriate selection above or write in below.
If Turquoise Care-Select MCO
Please Select
Blue Cross and Blue Shield of New Mexico
Presbyterian Health Plan
Molina Healthcare of New Mexico
United Healthcare Community Plan of New Mexico
If Private Insurance-Select Plan Provider
Please Select
Aetna
BCBS
Cigna
Presbyterian
Molina
United Healthcare
Western Sky
Other
Member ID#
*
Upload a copy of your insurance card
*
Browse Files
Drag and drop files here
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CONSENTS
Consent to Behavioral Health Treatment
I voluntarily consent to receive behavioral health services, including assessment, therapy, case management, and care coordination.
Click the radio button below if you consent to services from TribeAID.
*
I consent to Behavioral Health services
Consent for SUD/MAT Services
I consent to receive Substance Use Disorder services, including screening using ASAM criteria, counseling, recovery support, and medication-assisted treatment (MAT). I understand MAT may involve referral to a licensed provider outside of TribeAID and may include medications such as buprenorphine/suboxone or naltrexone.
Click the radio button below if you consent to SUD/MAT services from TribeAID.
I consent to SUD/MAT services.
Telehealth Consent
I understand that services may be delivered via phone or video, and I may stop telehealth at any time.
Click the radio button below if you consent to Telehealth services from TribeAID.
I consent to Telehealth services.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Receipt of HIPAA + 42 CFR Part 2 Notice
Acknowledgement of Notice of Privacy Practices (HIPAA) + 42 CFR Part 2 Confidentiality Notice as separate attachments sent via email along with the Welcome Letter from TribeAID.
*
I acknowledge receipt of the TribeAID Notice of Privacy Practices and 42CFR Part 2 Confidentiality Notice
RELEASE OF INFORMATION (ROI)
Would you like TribeAID to share or receive information with another provider?
*
Yes
No
Name of Person/Agency
Type of Information to Share
Behavioral Health Assessment
SUD/MAT Information
ASAM Summary
Diagnoses
Treatment Plan
Medications
Case Management Notes
Traditional Health Referrals
Other
If you would like other information shared or received, please describe below.
Purpose of Release
Expiration Date (Select a date you would like the release to expire
-
Month
-
Day
Year
Date
Signature
PRESENTING CONCERNS
Please describe what brings you to TribeAID, including mental health, substance use, or general wellness concerns:
*
MENTAL HEALTH HISTORY
Have you previously received counseling or therapy?
*
Yes
No
If YES, where and when?
Have you received any mental health diagnoses?
Are you currently taking psychiatric medications?
*
Yes
No
If YES, list medication(s), dose(s), and prescriber below.
Any past psychiatric hospitalizations?
*
Yes
No
If YES, when and where?
Over the last 2 weeks, how often have you been bothered by the following problems?
Little interest or pleasure in doing things.
Not at all
Several Days
More than half the days
Nearly every day
Feeling down, depressed or hopeless
Not at all
Several Days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious or on edge
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying
Not at all
Several days
More than half the days
Nearly every day
Do you feel safe at home?
*
Yes
No
Are you experiencing hallucinations or paranoia?
*
Yes
No
SUBSTANCE USE + MEDICATION-ASSISTED TREATMENT HISTORY
Which substances do you use or have used?
*
Alcohol
Opioids (heroin, fentanyl, other)
Methamphetamine
Cocaine
Cannabis
Benzodiazepines
Other
None
If you have used other substances not listed above, please share below.
For each selected substance, please provide: Age of first use; Frequency/amount; Route of use (smoked, injected snorted, oral); and Date of last use
Have you previously been prescribed Medication-Assisted Treatment (MAT) medications?
*
Yes
No
If YES, which medication(s)?
Please Select
Buprenorphine/Suboxone
Methadone
Naltrezone/Vivitrol
Other
Dosing information and prescriber
Reason for stopping MAT (if applicable)
Have you ever overdosed?
*
Yes
No
CULTURAL IDENTITY & STRENGTHS
Are there cultural or traditional practices you want include in your care?
*
Who are your current support people? (Family, Clan, Elders, Community Members, Friends, etc.)?
*
SOCIAL DETERMINANTS OF HEALTH
Please select any areas where you need support
*
Housing instability
Food insecurity
Transportation needs
Financial stress
Legal concerns
Domestic violence risk
Access to cultural/spiritual supports
Technology barriers
Childcare needs
None
Would you like Community Health, Peer Support or Case Management Support?
*
Yes
No
GRIEVANCE POLICY ACKNOWLEDGEMENT
I understand that I may file a grievance with TribeAID and will receive a response. I may also file a complaint with my Insurance provider or the New Mexico Health Care Authority
*
I understand and acknowledge the grievance policy.
CLIENT ACKNOWLEDGEMENT & SIGNATURE
I affirm that all information provided is accurate and I acknowledge receipt of the TribeAID intake materials and privacy notices.
Signature
*
Date
*
-
Month
-
Day
Year
Date
IF CLIENT IS UNDER 18:
Parent/Guardian Signature
Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
Submit
Should be Empty: