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Intake Form
"
*
" indicates required fields
Step
1
of
4
25%
Name
*
First
Middle
Last
Date of Birth
*
MM slash DD slash YYYY
Social Security Number
*
Gender
*
Male
Female
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Best Phone Number
*
Emergency Contact Name
*
Emergency Contact Phone
*
Is it Okay to Call?
*
Yes
No
Type of Appointment Reminder
*
Text
Email
Both
Phone Call
Appointment Reminder Email Address
Appointment Reminder Cell Phone
Family Size
*
Number of Dependent Children at Home Under 17
*
Are you Pregnant?
*
Yes
No
Mental Health or Substance Use
*
Mental Health
Substance Use
Substance Use Treatment Source of Payment
*
Medicaid
Health Insurance
Medicare
Self Pay
Other
Substance Use Treatment Other Source of Payment
Mental Health Treatment Source of Payment
*
Medicare
Medicaid
Personal Resources
Service Contract
Veterans Administration
Commercial Insurance
Workers Compensation
Other
Mental Health Treatment Other Source of Payment
Referral Source
Family/Friend
Clergy
School System
DSPD
Justice Referral
Self
Alcohol/Drug Abuse Provider
Mental Health Provider
Other Health Care Provider
Employer
Division of Workforce Services
DCFS
Other Community Referral
Marital Status
*
Married
Widowed
Divorced
Never Married/Single
Separated
Domestic Partner/Unmarried
Race (primary)
*
White
Asian
Other Single Race
Alaskan Native
Black/African America
Two or More Races
Pacific Islander
American Indian/Native American
Other
Other Race
Ethnicity (primary)
*
Cuban
Mexican
Puerto Rican
Not of Hispanic Origin
Other
Other Ethnicity
Language (If Other Than English)
Living Arrangement
*
24 Hour Residential
Foster Home (Adult or Child)
Institutional Setting
Jail
Homeless or Shelter
Private Residence-Dependent
Private Residence
Have you be civilly committed?
*
Yes
No
Have you ever or are you currently serving in the military?
*
Yes
No
Years of Education Completed
Enrolled in Education in the Last 3 Months?
*
Yes
No
Employment
*
Age 0-5
Disabled, Not Working
Employed Full-time 35+
Employed Part-time 35 hours
Unemployed/Not Seeking
Homemaker
Retired
Student/School Name
Supported/Transitional Employment
Unemployed Seeking
School Name
Have you previously had mental health treatment?
*
Yes
No
Have you ever been hospitalized at the Utah State Hospital?
*
Yes
No
Have you ever been treated at Davis Behavioral Health?
*
Yes
No
Have you ever taken any of the following medications?
*
Yes
No
(Clozaril, Seroquil, Zyprexa, Risperdal, Geodon)
A codependent client is someone seeking services because of problems arising from his/her relationship with an alcohol or drug abuser. Has been formally admitted for service to a program and/or has his/her own record
*
Yes
No
Number of arrests in the past 30 days
SUD ONLY - Days waiting to enter treatment
Tobacco Use
*
Never Smoked/Vaped
Former Smoker/Vape
Current Someday Smoker
Current Everyday Smoker
Use Smokeless Tobacco
Age of First Use
Primary Income Source
*
Disability, Workers Compensation
Legal Employment, Wages, Salary
Pension, Retirement, Social Security
Welfare, Public Assistance
None
Other
Other Income Source
Are you insured?
*
Yes
No
If you are uninsured, please complete the information below:
Earnings/Wages
Workers Compensation
SSI
SSD
Social Security
Retirement
Food Stamps
Welfare Benefits
Alimony/Child
Other Income
Total Monthly Income
Therapy Copay
Medical Copay
If you are uninsured, please complete the information below:
Insurance Company Name
*
Insurance Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Insurance Phone
*
Policy Number
*
Policy Holder Name
*
Policy Holder Date of Birth
*
MM slash DD slash YYYY
Photo of Insurance Card
*
Please upload a copy of both the front and back of the card in JPG or PNG format.
Drop files here or
Select files
Max. file size: 64 MB.
CO-PAY: It is my responsibility to pay my co-pay at the time of each session. Should my private insurance pay me directly, I understand I will be billed the full cost of service.
*
CO-PAY: It is my responsibility to pay my co-pay at the time of each session. Should my private insurance pay me directly, I understand I will be billed the full cost of service.
Cancellation and No Shows: I understand that I may be charged $25 no-show fee for missed appointments, or if I fail to cancel my appointment within 24hours.
*
Cancellation and No Shows: I understand that I may be charged $25 no-show fee for missed appointments, or if I fail to cancel my appointment within 24hours.
Insurance: I understand that changes in monthly income and insurance coverage may occur and that my co-payment may change as a result. I will notify Davis Behavioral Health of any changes immediately.
*
Insurance: I understand that changes in monthly income and insurance coverage may occur and that my co-payment may change as a result. I will notify Davis Behavioral Health of any changes immediately.
Billing Information: I agree that my family member, guardian, or person acting on my behalf may talk with DBH about my billing information and other billing matters related to my treatment at DBH.
*
Billing Information: I agree that my family member, guardian, or person acting on my behalf may talk with DBH about my billing information and other billing matters related to my treatment at DBH.
Collections: If for any reason your account has not been paid in full at discharge, an 18% collection fee will be added, and the account will be turned over to collections.
*
Collections: If for any reason your account has not been paid in full at discharge, an 18% collection fee will be added, and the account will be turned over to collections.
Privacy and Clients Rights: I have been made aware that the DBH Notice of Privacy Practices and Client Rights Statement can be found on the DBH Website
*
Privacy and Clients Rights: I have been made aware that the DBH Notice of Privacy Practices and Client Rights Statement can be found on the DBH Website
Advance Directives: I have been provided with information regarding Advance Directives and know that I may ask a therapist about any questions I may have.
*
Advance Directives: I have been provided with information regarding Advance Directives and know that I may ask a therapist about any questions I may have.
I currently have Advance Directives and a copy has been provided to DBH.
*
Yes
No
Medicaid Transportation: I am aware of how to access alternative methods of transportation for clients enrolled in the Prepaid Mental Health Plan.
*
Yes
No
Grievance/Appeals: I am aware of how to access Davis Behavioral Health's grievance and appeals process.
*
Yes
No
I give permission to Davis Behavioral Health to treat me for my behavioral health problems.
*
Yes
No
I agree to let DBH share my medical records with other medical providers through the Health Information Exchange HIE.
*
Yes
No
Jail Evaluation, if applicable, can be found in jail record.
Jail Evaluation, if applicable, can be found in jail record.
I consent to participation in telehealth services (video or other electronic method of treatment) from DBH. I understand that althought DBH implements security protocols to protect privacy or personal health information, with the use of technology there is some risk to privacy, such as breaches of confidentiality, theft of personal information, etc.
*
I consent to participation in telehealth services (video or other electronic method of treatment) from DBH. I understand that althought DBH implements security protocols to protect privacy or personal health information, with the use of technology there is some risk to privacy, such as breaches of confidentiality, theft of personal information, etc.
Signature
Client Name
*
Date
*
MM slash DD slash YYYY
Parent Name (For Minors)
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