Client Intake and Consent Form

Client Intake and Consent Form
IF YOU ARE FEELING LIKE YOU ARE IN DANGER OF HARMING YOURSELF OR OTHERS RIGHT NOW, STOP AND CALL 911 OR 988 IMMEDIATELY.
CLIENT INFORMATION
Name

First NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Date
Gender Identity
Tribal Affiliation(s): [If appropriate]
Contact Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method
Emergency Contact
Name
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
INSURANCE INFORMATION
Type of Insurance

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
If Private Insurance-Select Plan Provider
Member ID#
Upload a copy of your insurance card

Cancelof
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.
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.
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.
Signature
Date

MonthDayYear
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.
RELEASE OF INFORMATION (ROI)
Would you like TribeAID to share or receive information with another provider?
Name of Person/Agency
Type of Information to Share

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

MonthDayYear
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?
If YES, where and when?
Have you received any mental health diagnoses?
Are you currently taking psychiatric medications?
If YES, list medication(s), dose(s), and prescriber below.
Any past psychiatric hospitalizations?
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.
Feeling down, depressed or hopeless
Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Do you feel safe at home?
Are you experiencing hallucinations or paranoia?
SUBSTANCE USE + MEDICATION-ASSISTED TREATMENT HISTORY
Which substances do you use or have used?
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?
If YES, which medication(s)?
Dosing information and prescriber
Reason for stopping MAT (if applicable)
Have you ever overdosed?
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
Would you like Community Health, Peer Support or Case Management Support?
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
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

MonthDayYear
Date
IF CLIENT IS UNDER 18:
Parent/Guardian Signature
Date

MonthDayYear
Date
Please verify that you are human
Should be Empty:

Client Intake and Consent Form

IF YOU ARE FEELING LIKE YOU ARE IN DANGER OF HARMING YOURSELF OR OTHERS RIGHT NOW, STOP AND CALL 911 OR 988 IMMEDIATELY.

CLIENT INFORMATION

Contact Information

Emergency Contact

INSURANCE INFORMATION

CONSENTS

Consent to Behavioral Health Treatment

Consent for SUD/MAT Services

Telehealth Consent

Receipt of HIPAA + 42 CFR Part 2 Notice

RELEASE OF INFORMATION (ROI)

PRESENTING CONCERNS

MENTAL HEALTH HISTORY

Over the last 2 weeks, how often have you been bothered by the following problems?

Over the last 2 weeks, how often have you been bothered by the following problems?

SUBSTANCE USE + MEDICATION-ASSISTED TREATMENT HISTORY

CULTURAL IDENTITY & STRENGTHS

SOCIAL DETERMINANTS OF HEALTH

GRIEVANCE POLICY ACKNOWLEDGEMENT

CLIENT ACKNOWLEDGEMENT & SIGNATURE