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. If you need help downloading and completing the forms on your computer or smart phone, please refer to the above instructions on how to sign & submit the pre-assessment forms electronically.

• 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 Health Integration Management page.