Reaching HOPE Intake Paperwork

Last Name*
First Name*
Middle Initial
Preferred name
Date of Birth*

MonthDayYear
Address*
City*
State*
Zip*
County of Residence:
Is it okay for us to contact you by mail? yes*

YesNo
Social Security Number
I authorize communications via email*

YesNo

Email Address Entry Button
Email address:*
Primary Phone Number

Area CodePhone Number

Additional Phone Number

Area CodePhone Number

Is it okay to:

	Yes	No
Call this number
Leave a message at this number
Text this number

School/Employment*
Years of education*
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone Number*
Race and/or Ethnicity
Country of Origin
Languages Spoken
Spirituality and/or Religion
Sexual Orientation Identity
Romantic Relationship Status
Gender Identity*

FemaleMaleNonbinaryOther
Military Service

Active DutyVeteran

Support needed button
Support needed
Reaching HOPE offers supportive therapy--what can we help support you with? Are there any barriers to accessing services?
Sometimes life can feel overwhelming. Have you/your child ever experiences any of the following?

Suicidal thoughts (past)Suicidal thoughts (current)Homicidal thoughts (past)Homicidal thoughts (current)Psychiatric hospitalization
We believe that people are resilient and have many strengths and supports that help them survive difficult times. What or who has helped you/your child survive difficult time so far?
Family information
Family members: (please include each person's name, age, relationship to you, and if they live with you)
Are you filling out paperwork for a minor (under age 18)?*

YesNo

Minor Caregiver Information Button
Minor caregiver information
Parent / Caregiver Name*
Parent / Caregiver phone number (please specify if this is a home, cell or work number)*

Is it okay to*

	Yes	No
Call this number
Leave a message at this number

Does the caregiver live at the same address as the minor?*

YesNo

Caregiver Address Button
Caregiver address
Street Address*
City*
State*
Zip Code*
Protection Orders
Do you or your children have any current restraining, protective or no-contact orders?*

YesNo

Safety
Name of person order is against*
Relationship to client*
Name(s) of those covered / protected*

Crime Victim Intro
Have your or your child ever been the victim of a crime, experienced trauma or had social services involvement?*

YesNoMaybe

	Yes
Adams County
Brighton, CO
Commerce City, CO
Thornton, CO

Insurance Button
Insurance
Do you / your child have health insurance?*

YesNo

Insurance Information Button
Insurance Information
What insurance carrier do you / your child's have?
What insurance carrier do you / your child have?

MedicaidMedicareBCBSCignaUnitedAetnaKaiserOther
Please list your insurance number (e.g. Medicaid number, Group number, ID, etc)

TeleHealth Consent

Consent for the Use of Telehealth for Live Video Visits
I understand that to receive services via Telehealth, I consent to the following:

1. I hereby authorize Reaching HOPE to use the telehealth practice platform for telecommunication for therapy and assessment services.

2. I understand that technical difficulties may occur before or during the telehealth sessions which could result in my appointment beign unable to start on time or ending prematurely.

3. I accept that sessions will be provided via video; however, sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

4. For individuals who are utilizing Crime Victim Compensation: I understand that at present, telehealth is allowed by Crime Victim Compensation, and that this provision is (at present) temporary. If this allowance is not continued, I understand that I must either return to in-person therapy services or I will be responsible for payment of sessions.

5. I understand that all confidentiality and privacy agreements are the same whether sessions are conducted in person or via telehealth.

6. I shall have access to all information resulting from the session conducted via Telehealth as provided by applicable law

7. I have the option to refuse the delivery of services via Telehealth at any time without affecting my right to in-person services (if these are available).
I understand and agree to the above statements*

Yes
Initial*

Clear

Attendance Policy
Reaching HOPE is dedicated to providing quality and dependable care to all of our clients. A successful therapy experience also depends on your commitment to attending therapy sessions. Because of this, it is necessary that you keep appointment times and communicate scheduling needs as quickly as possible.

Our attendance policy requires 24-hour notice to cancel appointments except in cases such as serious illness or an unforeseen emergency. In general, we will take your word for emergencies; however, if emergencies or illnesses repeatedly interfere with your participation in therapy sessions, we will ask for documentation to excuse absences and waive fees. We allow two late cancellations (canceling with less than 24 hours notice) or no-shows (missing your therapy appointment with no notice) before we begin charging for the time our therapists have reserved for you. After the first late cancellation/no-show, you will receive a one time courtesy call to remind you of your appointment. After the second late cancellation/no-show you will receive an email reminding you of our attendance policy. If you do not show up for a session and do not call your therapist to communicate that there has been an emergency a third time, you will lose your spot on our calendar. In order to schedule another appointment, you must meet with our case manager to discuss barriers to attending sessions. It is very likely that your original appointment time will no longer be available if this occurs. If you do not meet with our case manager within 2 weeks of a missed appointment to discuss barriers and reschedule, you will be closed at Reaching HOPE and will need to call and schedule a new intake session in order to continue in therapy. In order to resume therapy services, all no-show/late cancellation fees must be paid prior to the next session, or a payment plan must be set up with an initial payment made prior to the next session.

It is important to note that all telehealth video appointments will be considered a no show if the client joins from a vehicle or location where they cannot obtain privacy.
Initials*

Clear

Support needed

Family information

Minor caregiver information

Caregiver address

Protection Orders

Crime Victim Information

Insurance

Insurance Information

Disclosure Statement

Legal Guardian Information

Additional Legal Guardian Information

Legal Guardian for individual able to consent for themselves

Agreement

TeleHealth Consent

Attendance Policy

Financial Fee Agreement

Signature