Intake Form

Client Intake Information

Share your demographic, contact, insurance, and treatment details so we can schedule your intake.
Today’s Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is the client a Child/Adolescent or an Adult?
Client’s Name

First NameLast Name
Client’s Preferred Name
Client’s Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Client/Parent or Guardian’s Email
example@example.com
Client’s Parent or Guardian’s name (if applicable)
Client’s Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Current School
Client’s Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Please provide your SSN and insurance ID to avoid scheduling delays.
Insurance ID # (Member ID/Subscriber ID)
Last 4 Digits of Social Security #
Highest level/grade of education achieved?
Gender
Race
Language
Marital Status
What type of insurance does the client have?
WHAT INSURANCE DOES THE CLIENT HAVE?

Other
Other insurance not listed above (if none, enter NONE)
What secondary insurance does the client have?
Is the person completing this form over the age of 18?
Emergency Contact Name
Relationship with Emergency Contact
Emergency Contact’s Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact’s Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Psychiatrist’s Name
Psychiatrist’s Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Does the client have any allergies?
Family history of mental health issues?
Others in home
What services are you interested in receiving from TriaPath?

Other
Reason for seeking services
Recent Treatment History in the past year?
Significant Medical Issues?
CONSENTS/RIGHTS INFORMATION:
TRIAPATH — NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Tria Health LLC, doing business as TriaPath (the "Practice"), is committed to protecting your privacy. We're required by federal law to safeguard your Protected Health Information ("PHI") — information that identifies you, or could reasonably be used to identify you — and to provide this Notice explaining our legal duties, our privacy practices, and the rights you have over your own health information.

YOUR RIGHTS
- Inspect and copy your PHI.
  You can request an electronic or paper copy of your PHI. We may charge a reasonable, cost-based fee.
- We may decline a request if we believe releasing the information could endanger your life or someone else's. You have the right to have that decision reviewed.
Ask us to amend your PHI.
- If you believe something in your record is incorrect or incomplete, you can ask us to correct it. We may ask you to submit your request in writing, along with your reasoning.
- If we decline, we'll explain why in writing, and you may add your own statement of disagreement to your record.
Request confidential communications.
- You can ask us to reach you in a specific way — a preferred phone number, or somewhere other than your home address, for example. We will accommodate all reasonable requests.
Ask us to limit what we use or share.
- You can ask us not to use or share your PHI for treatment, payment, or operations. We're not required to agree if it would affect the care we're able to provide.
- If you pay in full out of pocket for a service, you can ask us about that service with your health insurer.
- You can ask us not to share your information with specific people.
Request an accounting of disclosures.
- You can ask for a list of certain disclosures we've made of yo such list every 12 months at no charge.
Get a copy of this Notice.
- You can request a paper copy of this Notice at any time, even if you've agreed to receive it electronically.
Choose someone to act on your behalf.
- If someone holds your medical power of attorney or is your legrcise these rights on your behalf.
  File a complaint.
- If you believe your privacy rights have been violated, you can reach us directly: TriaPath
  Tanya Palacios: 757-630-2309 or info@triapath.com
  You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. We will never retaliate against you for filing a complaint.
Opt out of fundraising communications.
- If we ever contact you for fundraising purposes, you can opt out of future communications at any time.
OUR RESPONSIBILITIES
- We are required by law to maintain the privacy and security of your PHI.
- We will abide by the terms of this Notice.
- We will notify you if a breach of your unsecured PHI occurs.
- We may change the terms of this Notice as permitted by law; anly to PHI we already maintain as well as information we receive in the future.
Client Signature
TRIAPATH — CONSENT FOR SERVICES

This form is your Consent for Services (the "Consent"). Your clinician, counselor, peer support specialist, or other member of your TriaPath care team ("Provider") has asked you to read and sign this Consent before beginning services. Please review it carefully, and reach out to your Provider with any questions.

THE CARE PROCESS

Care at TriaPath is a collaborative process — you and your Provider work together, as partners, toward goals you help define. This approach is grounded in evidence-based practice and tends to work best when you're an active participant in it.

Getting started includes an intake process covering our policies, fees, emergency contacts, insurance, and a conversation about the type, expected duration, risks, and benefits of the services you're pursuing.

You and your Provider will develop — and periodically revisit — a treatment plan describing your goals, how often you'll meet, and the steps toward progress. Participation in services at TriaPath is voluntary, and ytime.

IN-PERSON VISITS

In-person sessions sboro and Durhamlocations. Please attend only if you're symptom-free from any
contagious illness, health and safetyprotocols, including reporting a possible exposure or positive
test for a communicperson visit.

TELEHEALTH SERVICES

Telehealth requireseo-capable device;your Provider will walk you through how to join a session.

Telehealth carries some inherent limitations — occasional technology disruptired to an in-personroom, and added complexity if a crisis arises mid-session — alongside real benebility, and notravel time. You agree to join sessions from a private space not to record any ser's permission.

CONFIDENTIALITY
Your Provider will formation withoutyour permission, except where required by law — including situations involvin you or someoneelse, suspected abuse or neglect, a court order, or coordinatof your care with oWhen informationmust be shared, we disclose only what's minimally necessary.

RECORD KEEPING
TriaPath maintains your treatment records in CheckPoint, an eleem protected withencryption, firewalls, and ongoing monitoring.

COMMUNICATION
Standard text messages and email are not secure and shouldn'tused to share sensi Provider about oursecure communication options. TriaPath staff do not communicawith clients througites.

COMPLAINTS

If you believe yourerly or unethically, you may raise it with them directly, or contact the appropriate professional licenscompany, or the U.S. Department of Health and Human Services.

ACKNOWLEDGMENT

By signing below, I confirm that I have received, read, and understood this Cone to its terms, andI consent to signing it electronically.
Client Signature
Should be Empty:

Client Intake Information

CONSENTS/RIGHTS INFORMATION: