Intake Form

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

Type of Appointment Reminder*

Text

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

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

Have you ever or are you currently serving in the military?*

Yes

Years of Education Completed

Enrolled in Education in the Last 3 Months?*

Yes

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

Have you ever been hospitalized at the Utah State Hospital?*

Yes

Have you ever been treated at Davis Behavioral Health?*

Yes

Have you ever taken any of the following medications?*

Yes

(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

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

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

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

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.*

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

Medicaid Transportation: I am aware of how to access alternative methods of transportation for clients enrolled in the Prepaid Mental Health Plan.*

Yes

Grievance/Appeals: I am aware of how to access Davis Behavioral Health's grievance and appeals process.*

Yes

I give permission to Davis Behavioral Health to treat me for my behavioral health problems.*

Yes

I agree to let DBH share my medical records with other medical providers through the Health Information Exchange HIE.*

Yes

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.*

Signature

Client Name*

Date*

MM slash DD slash YYYY