Adult MH Application

PROBLEM DESCRIPTION
Please describe the problem(s) that brings you to Evergreen at this time:
What would you like to see change by coming here?
Has there been mental health services involved before?

Yes No
If yes, where and when?
Are you interested in Parent Support or Family Sessions via Zoom or phone?

Yes No

Consent for Treatment & Authorization Form

Evergreen staff looks forward to helping you reach your goals. This form requests information to better serve you. All information between provider and patient is held strictly confidential unless you authorize release of confidential information; you present physical danger to yourself or other(s); or child/elder abuse or neglect is suspected. I am required by law to inform potential victims and legal authorities so that protective measures can be taken.

I.         Receipt of Required Notices: I hereby acknowledge that I have received a copy of Evergreen Youth & Family Services’ (EYS) Notice of Privacy Practices and a copy of your Additional Rights (Equal Access, Quality Treatment and Privacy, etc.).

II.       Consent for treatment and use of personal health information (PHI): I acknowledge that I have consented to receive mental health and related services from the staff of EYS which will be described in full in the treatment planning process. I understand that I must consent to receive services or I will not be served. I further acknowledge that I consent that my PHI, including information regarding chemical dependency, may be used for treatment, payment, or service referrals, subject to the uses and limitations set forth in state and federal law. Any additional uses of my PHI beyond those which are provided for in state and federal law shall require my authorization.

In some instances, counseling services may be covered by grant sources but if you do have insurance, we are required to use that source first and request that you please present that information. If applicable, upon verification of health plan/insurance coverage and policy limits, your insurance carrier will be billed for you and EYS will be paid directly by the carrier.   Please note that Evergreen has a policy that we will cover costs not paid by insurance companies for mental health services.
I, *
type your name
authorize the release of information regarding my care to my health plan for the payment of claims, certifications/ case management decisions, and other purposes related to the administration of benefits for my health plan.

I further authorize and request that my treating provider carry out mental health examinations, treatments, and/or diagnostic procedures, which now or during the course of my care are advisable. I understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement. I also understand that while the course of therapy is designed to be helpful, it may at times be difficult and uncomfortable.

I understand and agree to all of the above information.
Name *

First Name Last Name
Signature *

Clear
Parent/Guardian Name

First Name Last Name
Parent/Guardian Signature

Clear

INSURANCE INFORMATION

Please indicate how the services requested are to be paid.
Bill insurance carrier or other as indicated

Insurance (primary) Insurance (secondary) Medical Assistance Grant Funded - DO NOT HAVE INSURANCE (CVS/YIP)
Primary Insurance Carrier
Insurance Company Name
Other Pay Source
Primary Insurance Group #
Primary Insurance Policy #
Primary Insurance Amount Covered
Secondary Insurance Carrier
Insurance Company Name
Client Co-Pay (if applicable)
Secondary Insurance Group #
Secondary Insurance Policy #
Secondary Insurance Amount Covered
Medical Assistance #
FOR GRANT FUNDED PURPOSES. Do any of the following apply to you: Juvenile involvement such as misdemeanor, felony, probation history, juvenile detention center, chemical dependency center, court-ordered for mental health treatment, etc.

Yes No
Should be Empty:

	Yes	No
Worker’s Compensation Claim
Initiating a law suit against another party
Being sued by another party
Commitment for mental health or other reasons

	Yes	No
Have you ever felt you ought to cut down your drinking or drug use?
Have you ever had people annoy you by criticizing your drinking or drug use?
Have you ever felt bad or guilty about your drinking or drug use?
Have you ever had a drink or used drugs as an eye-opener first thing in the morning to steady your nerves or get rid of a hangover or to get the day started?

Evergreen Youth & Family Services