Intake and Forms

Please Be aware that Payment for your session or group is required at the time of service. There is a No Show Fee for clients who do not contact the office to cancel their appointment (This may be waived in the event of an emergency).

Intake and Forms are necessary for our staff to provide quality care. Much of the information that is required it is often of a sensitive nature, so keep in mind that High Country Behavioral Health is committed to your privacy.

All information you share at this agency, even your presence is confidential. No information will be shared with anyone without your written consent. There are certain legal exceptions to disclosure of information that are explained in the paperwork and discussed during each intake session. Just as you would wish to be treated with respect and dignity and that your visit here is confidential, please treat others in the same manner.

Federal confidentiality rules (42-CFR Part 2) prevent the use of any information we have obtained to be used to criminally investigate or prosecute any alcohol or drug client. Disclosure of client identifying information is permitted if authorized by a court order, after application showing good cause.

In some cases it is important for your counselor to discuss your care with others that are directly involved with your situation. This may be a judge, proscribing doctor, or family member. If this is seen as beneficial then you may be asked to sign a release which will allow this communication.

IT IS CRITICAL THAT WE RECEIVE YOUR PAPERWORK PRIOR TO YOUR FIRST APPOINTMENT TO AVOID ANY DELAY OF SERVICE.

Intake Packet

 Consent for Release of Protected Health Information

(This is PDF document.  You may print this document and bring it in to the office before your appointment. Also please select and fill out the correct Assessment below.)

Assessment information:

 

adult-assessment

child-assessment

Adolescent Assessment

Other Forms:

wydot-driving-record-request

prime-for-life-participant-registration

SA EVALUATIONS

To schedule an appointment for a Substance Abuse Evaluation we must first receive the following:

1- A $200 fee must be paid prior to scheduling an appointment

2- Our intake paperwork must be filled out. (Can find in this web site)

3- Adult Assessment must be filled out (Can find in this web site)

4-Your 10 year driving record – (Can obtain at your local DMV $5 charge)

5-The Officers arresting affidavit

6-All Court Documents pertaining to the charge

After all the information has been obtained, we will schedule an appointment. Please allow 2 hours for

an evaluation.

Fees and Insurance:

It is your responsibility to pay your fees on time and on a regular basis. We are a non-profit organization so your fees are necessary for us to continue to deliver services. Payment for your session is requested at the time of service. You will need the following documentation:

Proof of income for all household family members (if applicable). This can include the years W-2 tax form (first page of 1040) and 1 month’s worth of check stubs.

Proof of insurance (if applicable).

Your Medicaid card (if applicable).

Copy of your driver’s license.

Probation and parole and/or courts documents along with a copy of your past criminal history (if applicable).

We cannot complete your application without this information. Without the required information your appointment may have to be rescheduled

High Country Behavioral Health charges the rate of $120/session. If you do not have insurance or Medicaid HCBH bills on a sliding fee scale in which your fee is based on income and your ability to pay, prior years tax returns or current pay stubs will be required to appropriately set your fee. Please report any changes in your income or financial status, including the number of people dependent on your household income.  No one is denied services because of inability to pay.

High Country Behavioral Health accepts insurance:

Please note: If you do have insurance coverage for mental health and/or substance abuse services contact your insurance provider to find out:

If you must have preauthorization for your visits?

What is your co-pay?

Do you have a deductible?

Will you be required to pay your co-pay or whatever amount insurance does not pay for each visit at the time of service.

If you have any questions about your fee, please ask your therapist or the office manager.

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