Client Forms

Pre-Assessment Forms

After speaking with the Access Team, if you will be participating in a Telehealth appointment, fill out the Pre-Assessment Forms. You can access each form below by clicking on the name of the form in orange:

• Consent for Treatment
  • The following individuals may sign a Consent for Treatment:
    • Adults age 18 and older, unless declared incapacitated by a court of law (i.e. have a legally appointed guardian).
    • Minors age 13-17
    • Parents of a minor child (age 17 or younger) – adolescents should sign their own pre-assessment paperwork forms
    • Legal guardians
    • Kinship Caregivers – family members of a child under the age of 13 who are providing care for the child in the absence of a parent or legal guardian. Parent/guardian is not available.
    • If the client is unable to sign for themselves (i.e. under 13, or an adult with a legal guardian) someone who can sign consent must attend the assessment with the client, or must sign the Consent for Treatment in advance).
  • How to complete the Consent for Treatment:
    • Check all applicable boxes on pages 1
      • For packet material, only need to check the Financial Agreement box
    • Sign and date on page 4
    • Enter your Name & DOB on each page
    • Only Kinship Caregivers must complete page 5

• Financial Agreement
  • How to complete the Financial Agreement:
    • Check all applicable insurance boxes on page 1
      • Must include your ProviderOne ID # in the Medicaid section (example: 123456789WA)
    • Sign and date on page 2
    • Enter your Name & DOB on each page
• ROI (Release of Information) – see note below
  • If you are not intending to release, exchange, or disclose your medical records to another individual, then do not complete the ROI at this time.
  • Who can sign an ROI? If the client is 13 or above, they must sign the ROI; if the client is 12 or younger, a parent/guardian must sign the ROI.
  • In order to best assist your treatment, it is strongly encouraged to complete the following ROIs:
    • PCP
    • If a minor client is age 13 or above, we strongly encourage an ROI for the parent or guardian.
    • Other typical ROIs that we request from new clients include requests from School Counselors, Social Workers, other Medical Providers including recent hospitalizations, etc.
  • Instructions for completing an ROI:
    • Filling out an ROI – Tip Sheet
    • ROI Example – PCP
    • ROI Example – Emergency Contact

If this is a standalone request for information unrelated to submitting pre-assessment forms, please go to our Medical Records page.