Intake Packet 07-27-2026

New Client Packet
Thank you for choosing Jordan West Family Counseling. Please complete each section as accurately as possible.
CLIENT INFORMATION
Name

First NameLast Name
SOCIAL SECURITY NUMBER
PREFERRED NAME (OPTIONAL)
DATE OF BIRTH

MonthDayYear
Date
HOME OR MOBILE PHONE
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMPLOYER / OCCUPATION
REFERRED BY
Gender
Marital Status
EMERGENCY CONTACT
NAME
RELATIONSHIP
PHONE
Format: (000) 000-0000.
RESPONSIBLE PARTY (IF DIFFERENT FROM CLIENT)
PERSON RESPONSIBLE FOR ACCOUNT
RELATIONSHIP TO CLIENT
DATE OF BIRTH

MonthDayYear
Date
SOCIAL SECURITY NUMBER
PHONE
Format: (000) 000-0000.
ADDRESS (IF DIFFERENT)
EMPLOYER / OCCUPATION
9263 Redwood Road, Building 8, Suite B, West Jordan, Utah 84088 | 801-566-0749 | info@jordanwest.org

Insurance and Treatment Authorization
PRIMARY INSURANCE AND OTHER PAYMENT SOURCES
SUBSCRIBER NAME
RELATIONSHIP TO CLIENT
DATE OF BIRTH
INSURANCE COMPANY
MEMBER / ID NUMBER
PLAN / GROUP NUMBER
INSURANCE PHONE
Format: (000) 000-0000.
EAP COMPANY / AUTHORIZATION (IF APPLICABLE)
Front of Insurance card

Cancelof
Back of Insurance Card

Cancelof
ASSIGNMENT, RELEASE, AND CONSENT FOR TREATMENT
I certify that I or my dependent have insurance coverage and assign directly to my provider all insurance benefits otherwise payable to me for services rendered. I understand that I am ultimately responsible for all charges accumulated. I authorize Jordan West Family Counseling to release information necessary to secure payment of benefits and to use this signature on insurance submissions. I give permission for treatment of myself or my dependent by the assigned provider.
RESPONSIBLE PARTY SIGNATURE
RELATIONSHIP
DATE

MonthDayYear
Date
9263 Redwood Road, Building 8, Suite B, West Jordan, Utah 84088 | 801-566-0749 | info@jordanwest.org

Notice of Client Rights and Grievance Policy
We are committed to high-quality, respectful care.
YOUR RIGHTS
High-Quality Care
Receive respectful, dignified, and safe services.

Privacy and Safety
Receive services in a private and protective environment.

Independence
Receive care that respects your freedom and is least intrusive.

Informed Consent
Consent voluntarily to services except as legally permitted.

Participation
Be involved in service planning and include others of your choice.

Refusal
Refuse services or procedures without punitive consequences.

Notice of Termination
Receive prior notice and information about alternatives before involuntary termination.

Communication
Communicate privately with rights-protection programs.

Declaration of Treatment
Execute a mental-health treatment declaration.

Fee Transparency
Be informed in writing of fees.

Non-Discrimination
Receive services free of discrimination.

Grievance Process
File a grievance if your rights are violated.
YOUR RESPONSIBILITIES
Treat staff and others with courtesy and respect. Notify us at least 24 hours in advance when you cannot attend an appointment.
GRIEVANCE PROCESS
Step 1: Submit the grievance in writing to your therapist. They will respond within 10 days.

Step 2: If you are not satisfied, submit a written request for review by the Clinical Director within 30 days of the incident. The Clinical Director will respond within 10 days.

For assistance, contact the Clinical Director at 801-566-0749.
EXTERNAL ESCALATION
You may also contact the Utah Office of Licensing by calling 801-538-4242, emailing dlbc@utah.gov, or submitting an online form through the agency website.
CLIENT NAME
SIGNATURE
DATE
9263 Redwood Road, Building 8, Suite B, West Jordan, Utah 84088 | 801-566-0749 | info@jordanwest.org

JORDAN WEST FAMILY COUNSELING
Financial and Appointment Agreement
Please review the policies below before signing.
INSURANCE AND PAYMENT
1. Your insurance will be billed standard rates based on the CPT code. You are responsible for copays, coinsurance, deductibles, late-cancellation fees, missed-appointment fees, and services not paid by your insurance.
2. Jordan West Family Counseling bills primary insurance only. You are responsible for billing secondary insurance. Documentation can be provided when required.
3. Secondary insurance does not replace copay or coinsurance responsibilities.
4. If your insurance company does not respond in a timely manner, a statement may be sent to you. Please contact your insurer and respond promptly to any insurance correspondence so the claim can be processed.
CANCELLATIONS AND MISSED APPOINTMENTS
Appointments are reserved for you and your counselor. Cancellations require at least 24 hours notice. In the case of illness, please leave a message before 8:00 a.m. on the appointment day.
A missed appointment or cancellation with less than 24 hours notice may result in a $50.00 fee. The fee may need to be paid before another appointment is scheduled. Continued failure to keep appointments may result in dismissal from the practice.
Parents or guardians who are financially responsible for a child are responsible for knowing the child's appointment schedule and paying any applicable missed-appointment fee.
I authorize the release of medical, behavioral-health, or other information necessary to process insurance claims. I authorize payment of benefits to the provider and understand that I remain legally responsible for all fees due.
CLIENT / AUTHORIZED PERSON NAME
RELATIONSHIP TO CLIENT
SIGNATURE
DATE

MonthDayYear
Date
9263 Redwood Road, Building 8, Suite B, West Jordan, Utah 84088 | 801-566-0749 | info@jordanwest.org

JORDAN WEST FAMILY COUNSELING
Communication Preferences and SMS Consent
APPOINTMENT REMINDER SERVICE
Jordan West Family Counseling uses an automated reminder service to improve communication with clients. The service may communicate through mobile phones, landline phones, and email accounts. You remain in control and may change or stop reminder messages at any time. Jordan West Family Counseling does not charge a fee for this service. Standard message, calling, and data rates may apply.
PRIVACY, TIMING, AND CANCELLATION
Voice calls, texts, and email may involve privacy risks because other people may access your phone, voicemail, email, or shared device. Jordan West Family Counseling will use reasonable care but cannot guarantee the privacy or security of these communications. Reminder calls or messages are generally sent between approximately 6:00 p.m. and 8:00 p.m. on the day before your appointment. Contact the office at least 24 hours in advance to avoid a $50.00 late-cancellation or no-show fee. Example reminder: "John/Mary, this is an important reminder that it is time for your appointment with [therapist name]."
PREFERRED REMINDER METHOD - SELECT ONE
PHONE / MOBILE NUMBER
EMAIL ADDRESS
INITIALS IF CHOOSING NO REMINDERS
SMS TEXT MESSAGING CONSENT
Jordan West Family Counseling may send text messages for appointment reminders and confirmations, scheduling or rescheduling, billing or payment communications, general office communication, and administrative updates. Text messages are not intended for emergencies, crisis situations, urgent clinical matters, or highly sensitive confidential information.
CLIENT OR GUARDIAN SIGNATURE
DATE

MonthDayYear
Date
9263 Redwood Road, Building 8, Suite B, West Jordan, Utah 84088 | 801-566-0749 | info@jordanwest.org
JORDAN WEST FAMILY COUNSELING

Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can access it. Please review it carefully.
OUR PRIVACY DUTIES
Jordan West Family Counseling is required to maintain the privacy of your health information and provide notice of its legal duties and privacy practices. We will not use or disclose your health information except as described in this Notice or as otherwise permitted or required by law. Protected health information includes information created or obtained while providing services, including symptoms, medical history, examination and test results, diagnoses, treatment, future care, and billing records.
HOW WE MAY USE YOUR INFORMATION
Treatment: A provider or assistant may obtain and record treatment information. With written authorization when required, a provider may consult with another specialist, send referral information for testing, or report progress to a primary-care or referring provider.
Payment: We may submit requests for payment to your insurance company. A claim may include information that identifies your diagnosis, procedures, and services.
Health care operations: We may use or share information as necessary for quality assessment, quality improvement, outcome evaluation, training, credentialing, medical review, legal services, insurance, transcription, and similar operational functions. Business associates are required to protect confidentiality.

YOUR HEALTH INFORMATION RIGHTS

☐ Request restrictions on certain uses or disclosures in writing.

☐ Obtain a paper copy of this Notice.

☐ Request to inspect and copy your billing record in writing.

☐ Obtain an accounting of disclosures as required by law.

☐ Revoke previous authorizations in writing, except where action has already been taken.

☐ Request reasonable methods for communicating health information.
You have the right to review this Notice before signing an acknowledgment that you received or had access to it.
9263 Redwood Road, Building 8, Suite B, West Jordan, Utah 84088 | 801-566-0749 | info@jordanwest.org

JORDAN WEST FAMILY COUNSELING
Notice of Privacy Practices - Continued
Questions or complaints may be directed to Jordan West Family Counseling at 801-566-0749.
We reserve the right to amend our privacy and access practices. If our practices change, we will revise this Notice. You may request a revised copy by contacting the office.
- Maintain the privacy of your health information as required by law.
- Provide notice of our duties and privacy practices.
- Abide by the terms of this Notice.
- Notify you if we cannot accommodate a requested restriction or request.
- Accommodate reasonable requests regarding communication methods.
REQUESTS OR COMPLAINTS
If you have questions, want additional information, or believe your privacy rights have been violated, contact Jordan West Family Counseling at 801-566-0749. You may also file a complaint with the U.S. Department of Health and Human Services. We will not require you to waive this right and will not retaliate against you for filing a complaint.
OTHER DISCLOSURES AND USES
Family and friends: We do not disclose protected health information to family members unless authorized, required, or permitted by law.
Appointment reminders and treatment information: We may contact you or leave a message regarding appointments, lab results, prescriptions, or billing information, consistent with your communication preferences.
Workers compensation: We may disclose information as necessary to comply with workers-compensation laws.
Abuse, neglect, and domestic violence: We may disclose information to public authorities as allowed or required by law.
Law enforcement and legal proceedings: We may disclose information when required by court order, subpoena, discovery request, or other lawful process, and when permitted by law to prevent or lessen a serious and imminent threat to health or safety.
Other uses: Other uses and disclosures will be made only as authorized by law or with your written authorization. You may revoke an authorization as previously described.
ACKNOWLEDGMENT
By signing below, I acknowledge that I received or had the opportunity to review the Notice of Privacy Practices. My signature confirms receipt or access; it does not mean that I agree with every statement in the Notice.
CLIENT NAME
SIGNATURE
RELATIONSHIP TO CLIENT
DATE

MonthDayYear
Date
9263 Redwood Road, Building 8, Suite B, West Jordan, Utah 84088 | 801-566-0749 | info@jordanwest.org

JORDAN WEST FAMILY COUNSELING
Telehealth Consent Form
Telehealth may be provided by secure video or, when needed, by telephone.
CLIENT NAME
1. Consent to telehealth I authorize Jordan West Family Counseling to use telehealth for evaluation, testing, diagnosis, and treatment related to my care.
2. Technology limitations I understand that technical difficulties may occur before or during a session and may delay, interrupt, or end the appointment.
3. Video or telephone sessions I understand that sessions may be conducted by video. If video cannot be used because of internet speed or other technical limitations, the session may be conducted by telephone.
4. Insurance and fees I understand that my insurance may not cover all telehealth services and that I may be responsible for charges not paid by my insurance company.
5. Records and privacy I understand that telehealth services will be documented in my health record for evaluation, analysis, and treatment purposes, and Jordan West Family Counseling will keep my information private as required by law.
CLIENT OR GUARDIAN SIGNATURE
DATE

MonthDayYear
Date
9263 Redwood Road, Building 8, Suite B, West Jordan, Utah 84088 | 801-566-0749 | info@jordanwest.org
CARDHOLDER INFORMATION

Release of Confidential Mental Health Information
PEOPLE YOU AUTHORIZE
List the people Jordan West Family Counseling may speak with about your treatment or progress.
Name

First NameLast Name
DATE OF BIRTH

MonthDayYear
Date

PEOPLE YOU AUTHORIZE

Rows	NAME / RELATIONSHIP	PHONE	EMAIL
1
2
3

SPECIAL PERMISSIONS
Your mental-health information and communication of that information are essential to treatment. We prefer to speak directly with each client, but we understand that family members or other individuals may be involved in treatment and progress. We cannot discuss your treatment or progress with anyone, including parents, spouses, family members, caseworkers, attorneys, guardians ad litem, judges, or court clerks, unless they are listed below or disclosure is otherwise required or permitted by law.
For children over age 12, consent may be requested before a counselor or Jordan West Family Counseling communicates with parents about progress. For clients in custody, communication may occur with foster parents, caseworkers, guardians ad litem, the Attorney General, or a judge as permitted or required. Clients referred by a court may authorize communication with probation officers, judges, and court clerks for updates, treatment progress, treatment summaries, and treatment termination.
I authorize the use or disclosure of my personal mental-health information as described above. If the client is under age 18, a parent or guardian may sign.
SIGNATURE
RELATIONSHIP TO CLIENT
DATE

MonthDayYear
Date
AUTHORIZATION
This authorization applies only to mental-health treatment provided by Jordan West Family Counseling. Other providers may require a separate authorization. The client or Jordan West Family Counseling may terminate this authorization in writing.
Authorization terminated as of:

MonthDayYear
Date
9263 Redwood Road, Building 8, Suite B, West Jordan, Utah 84088 | 801-566-0749 | info@jordanwest.org

New Client Packet

CLIENT INFORMATION

EMERGENCY CONTACT

RESPONSIBLE PARTY (IF DIFFERENT FROM CLIENT)

Insurance and Treatment Authorization

PRIMARY INSURANCE AND OTHER PAYMENT SOURCES

ASSIGNMENT, RELEASE, AND CONSENT FOR TREATMENT

Notice of Client Rights and Grievance Policy

YOUR RIGHTS

YOUR RESPONSIBILITIES

GRIEVANCE PROCESS

EXTERNAL ESCALATION

Financial and Appointment Agreement

INSURANCE AND PAYMENT

CANCELLATIONS AND MISSED APPOINTMENTS

JORDAN WEST FAMILY COUNSELING

Communication Preferences and SMS Consent

APPOINTMENT REMINDER SERVICE

PRIVACY, TIMING, AND CANCELLATION

PREFERRED REMINDER METHOD - SELECT ONE

SMS TEXT MESSAGING CONSENT

Notice of Privacy Practices

OUR PRIVACY DUTIES

HOW WE MAY USE YOUR INFORMATION

Notice of Privacy Practices - Continued

REQUESTS OR COMPLAINTS

OTHER DISCLOSURES AND USES

ACKNOWLEDGMENT

JORDAN WEST FAMILY COUNSELING

Telehealth Consent Form

CARDHOLDER INFORMATION

Release of Confidential Mental Health Information

PEOPLE YOU AUTHORIZE

SPECIAL PERMISSIONS

AUTHORIZATION

Mental Health History and Current Concerns

PAST TREATMENT OR IMPORTANT HISTORY

CURRENT CONCERNS - CHECK ALL THAT APPLY

SAFETY - PLEASE ANSWER EACH ITEM

PRIMARY REASON FOR VISIT / OTHER INFORMATION

CLIENT ACKNOWLEDGMENT