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 6

Name
This field is for validation purposes and should be left unchanged.
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

Set Free Alaska

Mat-Su Office 907-373-4732

Homer Office 907-416--7569

Initial Intake Form

Step 1 of 6

Client Profile

Demographics

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

Consent

Adverse Childhood Experience (ACE) Questionnaire

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