Initial Intake Form

Instructions: The Client Intake Form is to be completed prior to the initial assessment. Completion of this form is required. Please check the boxes, or fill in the blanks below for each question.

Step 1 of 10

BEFORE YOU BEGIN*
I understand I must have valid ID before the day of my assessment or I will be rescheduled.
Completion of this form is required before assessment. Please note Set Free Alaska does not serve sex offenders at this time.*
I Understand the Statement Above

Consent
Consent*
I understand that the information in this correspondence may contain information relating to my substance use diagnosis and/or treatment, mental health diagnosis and/or treatment, and/or Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS)
Consent*
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.
Consent*
I understand and consent to the use of all electronic communication, text messaging and email and that they all have potential security risks.
Consent*
I Consent For Set Free Alaska To Verify My Health Insurance Coverage.
Signature of Client*
Client Name*
First Last
Date*
MM slash DD slash YYYY
Signature of Parent, Guardian or Representative
Relationship to Client
Date
MM slash DD slash YYYY

DISCLOSURE OF ALCOHOL AND DRUG TREATMENT INFORMATION
I UNDERSTAND THAT MY ALCOHOL AND/OR DRUG TREATMENT RECORDS ARE PROTECTED UNDER THE FEDERAL REGULATIONS GOVERNING CONFIDENTIALITY AND DRUG ABUSE 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 AND 164, AND CANNOT BE DISCLOSED WITHOUT MY WRITTEN CONSENT UNLESS OTHERWISE PROVIDED FOR BY THE REGULATIONS.

I UNDERSTAND THAT I MAY BE DENIED SERVICES IF I REFUSE TO CONSENT TO A DISCLOSURE FOR THE PURPOSES OF TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS, IF ALLOWED BY STATE LAW. I WILL NOT BE DENIED SERVICES IF I REFUSE TO CONSENT TO A DISCLOSURE FOR OTHER PURPOSES.

I HAVE HAD EXPLAINED TO ME AND FULLY UNDERSTAND THIS REQUEST/AUTHORIZATION TO RELEASE AND/OR OBTAIN RECORDS AND INFORMATION, INCLUDING THE NATURE OF THE RECORDS, THEIR CONTENTS, AND THE CONSEQUENCES AND IMPLICATIONS OF THEIR RELEASE. I UNDERSTAND THAT ONCE MY INFORMATION IS RELEASED, SFA CANNOT PREVENT THE REDISCLOSURE OF THAT INFORMATION, HOWEVER DOES PROVIDE A STATEMENT OF PROHIBITION AGAINST REDISCLOSURE OF PROTECTED HEALTH INFORMATION WITH DISCLOSURES MADE.

I UNDERSTAND THAT I MAY REVOKE A CONSENT IN WRITING AT ANY TIME, EXCEPT TO THE EXTENT THAT ACTION BASED ON THIS CONSENT HAS ALREADY BEEN TAKEN. SEE RECEPTION FOR INSTRUCTIONS TO REVOKE A CONSENT. IF TREATMENT IS MANDATED AS PART OF PROBATION REQUIREMENTS, A CONSENT MAY NOT BE REVOKED UNTIL CONDITIONS OF PROBATION ARE MET OR PROBATION ENDS.

I HAVE A RIGHT TO RECEIVE A COPY OF THIS SIGNED AUTHORIZATION. I ALSO UNDERSTAND THAT UPON MY WRITTEN REQUEST, SFA MUST PROVIDE A RECORD OF DISCLOSURES MADE FOR LEGAL, ADMINISTRATIVE OR QUALITY ASSURANCE PURPOSES.

NOTICE
PROHIBITING REDISCLOSURE OF ALCOHOL AND DRUG TREATMENT INFORMATION

This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose (see § 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65.
Signature of Client, Parent and or Legal Guardian*
Name*
First Last
Date*
MM slash DD slash YYYY

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 so that we can assist you. Please call (907) 746-4732 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*
Date*
MM slash DD slash YYYY

Telehealth Informed Consent
Distance Counseling to Supplement Traditional Counseling
I acknowledge that I have received, read (or have had read to me), and understand the information provided to me about substance abuse treatment I am considering through distance counseling with the use of technology.
1. I consent to the use of Tele-counseling - Support and insightful discussion is done via telephone/personal cellular device at a designated time agreed upon by client and counselor.
2. I consent to Video conferencing on the web - Counseling can continue for clients through the internet videoconferencing programs that are secure and HIPAA compliant such as, but not limited to Zoom, Skype for Business, Microsoft Teams, or other similar programs. Counselor may also use webinar functionality of Microsoft online portal that will allow counselors to post notes, handouts or homework.
3. I consent that while attending individual/group sessions online or using a personal cellular device, family members, co-workers and friends will not be present. My participation will be conducted in a private non-public secure area free from distraction. It is highly recommended to utilize headphones during sessions.
4. I consent that I will only communicate through a computer/personal cellular device that I know is safe, i.e. wherein confidentiality can be ensured (Be sure to fully exit all online counseling sessions). I further consent, that if we are unable to connect or are disconnected during a session due to a technological breakdown, I will try to reconnect within 10 minutes. If reconnection is not possible, I will call to schedule a new session time.
5. I consent to contact 911 or go to the nearest emergency room if I am experiencing a crisis situation.
6. Electronic Confidentiality including Audio/Visual, Chat, Phone communication. I consent to transmit therapeutic chat exchanges using encrypted means such as Zoom, SKYPE or Microsoft Teams and understand that use of cell phones, text messages are not confidential. I agree to keep computer files referencing our communication using secure and encrypted measures.
7. I understand that non-compliance will result in being dropped from the session or prevented from further participation in telehealth.
Name of Client*
First Last
Signature of Client*
Date*
MM slash DD slash YYYY
Name of Parent, Guardian or Representative
First Last
Relationship to Client
Date
MM slash DD slash YYYY
Are You Human? Answer This: 2+1=?*
Email
This field is for validation purposes and should be left unchanged.

Set Free Alaska

Mat-Su Office 907-373-4732

Homer Office 907-235-4732

Initial Intake Form

Step 1 of 10

Client Profile

Demographics

In case of emergency Set Free Alaska Staff has my permission to notify any of the following persons:

Consent

DISCLOSURE OF ALCOHOL AND DRUG TREATMENT INFORMATION

NOTICE

Adverse Childhood Experience (ACE) Questionnaire

Client Financial Responsibility Agreement

Referring Agency Form

Telehealth Informed Consent

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