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Mat-Su Office 907-373-4732
Homer Office 907-235-4732
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Phone 907-373-4732
Fax 907-746-4749
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Home
About
Meet The Staff
SFA Board of Directors
Founders Video
Strategic Plan
Annual Report
Press & Support
Services
Outpatient Services – Mat-Su
Outpatient Services – Homer
Children / Adolescent Services
Women’s Residential Treatment
Men’s Residential Treatment
Assessment
Costs
Notice of Privacy Practices
Donations
Testimonies
Employment
Contact
Mat-Su Office 907-373-4732
Homer Office 907-235-4732
Connect
Connect
Set Free Assessment Form - Mat-Su
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BEFORE YOU BEGIN
*
I understand I must have valid ID before the day of my assessment or I will be rescheduled.
Client Profile
Name
*
First
Last
Client Gender
*
Male
Female
If female, maiden name required.
*
Mailing Address
*
Street Address
City
Alabama
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Armed Forces Americas
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State
ZIP Code
Email
Enter Email
Confirm Email
Main Contact Phone
*
Other Phone
Date of Birth
*
Month
Day
Year
Social Security Number
*
SACC Client Id Number (if known)
Demographics
Races(s): Check all that apply
*
American Indian
Asian
Caucasian
Native Hawaiian
Pacific Islander
Alaska Native
Aleut
Athabascan
Haida
Tlingit
Tsimshian
Yupik
Other Alaska Native
Other
Unknown
Ethnicity: Check One
*
Not Spanish / Hispanic / Latino
Chicano
Cuban
Hispanic
Mexican American
Puerto Rican
Spanish / Hispanic / Latino
Unknown
English Fluency: Check One
*
Excellent
Good
Moderate
Poor
Not at all
No response
Education: Check one
*
If K-11, state how many years in the box below.
GED
High School Diploma
Vocational Training
Special Ed Classes
Bachelors Degree
Graduate Work (no degree)
Masters Degree
Doctorate Degree
Post Secondary 1 yr
Post Secondary 2 yrs
Post Secondary 3 yrs
Post Secondary 4+ yrs (no degree)
Unknown
Highest Level Education Completed
*
Veteran Status: Check one
*
Never in Military
Reserves / National Guard - Combat
Reserves - No Combat
Military Dependant
Active Duty - Combat
Active Duty - No Combat
Retired From Military
Verteran Other Eras
Vietnam Vet - Combat
Vietnam Vet - No Combat
Unknown
Special Needs: Check all that apply
*
None
No Response
Dev Disabled
Major Difficulty in Ambulating
Moderate to Severe Medical Problems
Severe Hearing Loss or Deaf
Traumatic Brain Injury
Visual Impairment or Blind
Unknown
Intake Information
Initial Contact: Check one
*
Phone
Drop In (Orientation)
Hospital / On Call Intervention
Community Service Patrol
By Appointment
Other
City / Village: Check one
*
Anchorage
Eagle River
Wasilla
Palmer
Other location outside of Anchorage bowl area (specify below)
Source of Referral: Check one
*
ASAP
Federal Probation
Office of Children's Services
Department of Corrections / Jail
Correctional Agency (Probation of Parole)
Court - Civil Proceedings
Court - Criminal Proceedings
Individual / Self Referral
Crisis / Respite Care
Alaska Native Hospital
Detox or Residential Program
API
Assisted Living Facility
Attourney
Developmental Disabilities Residential Program
Developmental Disabilities Program
Drug Program, Employer (EAP)
Halfway House
Nursing Home
Other Mental Health (not including psychiatrist)
Other
Only Required if Female: Pregnant?
Yes
No
If Yes: Due Date
MM slash DD slash YYYY
Injection Drug User (within the last 12 months)
*
Yes
No
Unknown
Primary Presenting Problem:
*
Alcohol & Drugs
Alcohol
Drugs
Secondary: (Specify From List Below. If none put N/A)
*
Tertiary: (Specify From List Below. If none put N/A)
*
(Alcohol & Drugs Alcohol Only; Drugs Only; Suicide attempt/threat; Child abuse victim; Sexual abuse victim; Domestic violence victim; Eating disorder; Thought disorder; Depression; Social/interpersonal (not family); Coping with daily roles/activities; Marital; Family (non marital); Medical/somatic; Psychological/emotional; Financial; Poverty; Child abuse perpetrator; Sexual abuse perpetrator; DV perpetrator; None; Other; Unknown)
Presenting Problem(s) in clients own words: Why is the client seeking services?
*
Special Initiative: Check all that apply
*
Theraputic Courts
Women With Children
Aquired Brain Disorders
Adult - Organic Disorder without SED
Adult - Severe & Persistent Mental Illness
Adult - Severe Emotional Disturbance
Fetal Alcohol Syndrome
HIV
Methadone
Persistant & Disabling Personality Disorder
Psychiatric Emergency Services
Traumatic Brain Injury
None
Consent
*
By signing and submitting this form, I am giving consent to Set Free Alaska to enter my identifying information on Alaska’s Automated Information Management System (AKAIMS). Furthermore, I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that the agencies identified above may not condition my treatment on whether I sign a consent form, but that in certain circumstances I may be denied treatment if I do not sign a consent form.
Signature
*
Client Financial Responsibility Agreement
Thank you for choosing Set Free Alaska, Inc. (hereafter referred to as “SFA”) as your treatment provider. We are committed to providing you with quality services. SFA must obtain a valid copy of your identification, current Insurance information and proof of income when applicable.
Insured (Including Medicaid):
All services are provided to you with the understanding that you are responsible for the cost regardless of your insurance coverage. If you would like to know the cost of a service, please inquire prior to treatment. Please be aware that not all services are a covered benefit with different insurance companies. You are responsible for knowing what services are or are not covered.
**Important Notice Regarding Medicaid.
** Please be aware that, at this time Medicaid will only pay for one assessment every six months. The assessment must have a diagnosis or level of care for Medicaid to pay for it. If you don’t have a diagnosis or level of care you will be billed for an assessment at the sliding scale fee. **
Your insurance policy is a contract between you, your employer, and the insurance company. We are NOT a party to that contract. It is your responsibility to notify this office immediately if your insurance coverage changes. It is your responsibility to understand your coverage and benefits, including pre-certifications, referral and authorization requirements, and to be sure all insurance information is current.
When possible, we will bill your primary insurance company (including Medicaid) as a courtesy, but you are still ultimately responsible for payment of all services you receive. If your insurance company does not respond within 60 days, we will follow up with an inquiry on your behalf. If, however, your insurance does not respond within 60 days of claim submission, an invoice will be sent to you. You should call your insurance to question why the claim is not paid. Our office will assist you only after you have contacted your insurance.
Insured/Non-Insured Payments:
We accept cash, check, debit card, and credit cards for MasterCard and Visa.
Insured:
Unless a payment plan has been agreed upon prior to the date of service, we will collect your deductible, co-pay, and payment for any uncovered services as well as the client’s portion as determined by insurance at the time of service.
Non-Insured/Under-Insured:
If you do not have medical insurance the following applies: Unless a prior financial agreement plan has been signed and payments are current, you will be responsible for a minimum payment at the time of service for the service to be received that day, as well as any previous outstanding balance. We offer a 20% discount for payment in full at time of service.
Sliding Scale:
I understand that to be eligible for the sliding fee scale I must provide current proof of income. (Most resent paystub or tax return). I also understand that I must notify Set Free Alaska of any changes or increases that cause me to be no longer eligible for sliding scale.
No-Show Fee:
There is a $25.00 fee for missed appointments not cancelled within 24 hours of the scheduled appointment time. These charges are your responsibility and cannot be billed to insurance or Medicaid. This fee maybe waived situationally.
Collection Fee:
There is a $25.00 fee for collecting UA samples using an instant-read cup. Use of Instant Read cups are at the discretion of the counselor providing the service.
ASAP Clients:
In the event that there is an outstanding balance after sessions are complete, SFA will report to ASAP that client has attended all recommended sessions; however, is not treatment complete due to an outstanding balance.
**We do understand that temporary financial problems may affect timely payment. We encourage you to communicate any such problems with the office manager. Please call (907) 373-4732 for account management. **
Release of Information:
I assign benefits of my medical insurance contract or Medicaid to SFA and authorize payment directly to SFA. I authorize SFA to release medical information to payers as required for payment of claims for medical services.
Delinquent Accounts:
Any unpaid charges over 90 days old will be considered for an outside collection agency. The Collection agency will receive client identifying, contact and financial information. You are responsible for any collection, legal, or court fees incurred in the collections process. Your clear understanding of our Financial Policy is important to our relationship. Please ask if you have any questions about our fees, Financial Policy, or your financial responsibility. We will discuss our professional fees at any time.
Consent
*
I have read and understand the payment policy and agree to abide by its guidelines:
Client Name
*
First
Last
Client / Guardian Signature
*
Email
This field is for validation purposes and should be left unchanged.
