New Patient Registration Packet (11/12/25)

CLIENT/PATIENT ACKNOWLEDGMENT & CONSENT TO TREAT
Consent to Services: I voluntarily consent that I will participate in healthcare services (which may include, but is not limited to, behavioral health, medical care, psychiatric, and/or substance use treatment) at Solvista Health. All services will be provided by appropriately qualified staff and may include a care team to provide individualized services by a coordinated group of integrated professionals. This consent remains valid for the duration of services unless revoked.

Potential Benefits of Treatment: Solvista Health's goal is to provide best in class, quality care that utilizes evidence-based practices to guide individualized care decisions. Reaching goals and improving quality of life often requires change, which can be hard. Research shows that likelihood of success is more often achieved when I am an active participant. It is important to keep my care team informed of any changes, barriers, or difficulties that I am experiencing as it relates to my

Billing and Payment Obligation: Solvista Health does not believe anyone should be denied care because of their ability to pay. As a client/patient, I am required to maintain up to date, accurate information regarding my insurance or payment preference, and I agree to assist Solvista Health in submitting claims for payment and/or helping obtain payment. I agree to follow Solvista Health's Financial and Collections Policies. This includes, but is not limited to, paying any copays at the time of service and/or paying any deductibles in a timely manner. If I am unable to pay or am having difficulty making payment, I understand Solvista Health has financial assistance programs available that I can apply for.

Telehealth Services: I consent to receive services via telehealth, where I would interact with a provider in a live format but who is not physically present with me. I understand and agree neither party will record the service without consent of the other party and that the provider is only responsible for limited HIPAA protections at my location. I will let staff know if I prefer to receive services in person, Solvista Health will attempt to accommodate my request. I understand that I may change my preference to receive telehealth services at any time for any reason.

Limits of Participation in Custody and Court Proceedings: Solvista Health reserves the right to decline to participate in court proceedings. I agree not to subpoena Solvista Health in any proceeding that may jeopardize the therapeutic relationship between me and my provider. This includes, but is not limited to, requests to testify in court, write reports to the court, and/or make custody recommendations.
Solvista
Acknowledgments: Information regarding Solvista Health's practices are provided as part of this informed consent. Please review these documents carefully and initial below. My initials indicate that I have read, understand, and agree to each of the following documents.
Client/Patient Rights and Responsibilities*
Initials
Solvista Health Notice of Privacy Practices*
Initials
No Surprise Billing*
Initials
Mental Health Professionals Mandatory Disclosure*
Initials
Crisis/Emergency Information*
Initials
Duration of Consent To Treat: This consent is valid for the duration of time I receive services at Solvista Health or until Inotify Solvista Health of my intent to discontinue services.

I understand if I withdraw consent, my services with SolvistaHealth will end.I understand that Solvista Health may disclose information related to my services to RMHP for payment, health care andcare coordination purposes. I also understand that I may opt out and not consent to disclosure of information regarding care coordination purposes.
OPTIONAL: I choose to “opt out” and prevent the disclosure of my information for care coordination purposes to RMHP (Rocky Mountain Health Plans)
I have read and understand the above information, have had an opportunity to ask questions about this information, and I consent to receive healthcare services from Solvista Health. If applicable, I also attest that I am the legal guardian and have the right to consent for the treatment of this minor.
Client/Patient/Parent or Guardian Signature*

Clear
Todays Date*

MonthDayYear
Date
Client/Patient Name printed*
If you are the Parent/Guardian of the client/patient, please sign below
Parent/Guardian Signature

Clear
Todays Date

MonthDayYear
Date
Parent/Guardian Name printed
Relationship to Client/Patient
Name of Client:

First NameLast Name

Solvista Health

ADULT PATIENT HEALTH QUESTIONNAIRE (PHQ 9)
NAME*
DATE*

MonthDayYear
Date
Over the last 2 weeks, how often have you been bothered by any of the following problems?

0- Not at all, 1- Several days, 2-more than half the days, 3-nearly every day
1. Little interest or pleasure in doing things.*
2. Feeling down, depressed, or hopeless*
3. Trouble falling or staying asleep, or sleeping too much*
4. Feeling tired or having little energy*
5. Poor appetite or overeating*
6. Feeling bad about yourself, or that you are a failure or have let yoursel or your family down*
7. Trouble concentrating on things, such as reading the newspaper or watching television*
8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual*
9. Thoughts that you would be better off dead, or of hurting yourself*
TOTAL
10. If you checked off any problems, how difficult have these problems made it for you to do you work, take care of things at home, or get along with other people?*

Drug Abuse Screen Test. DAT-10
The following questions concern information about your possible involvement with drugs not including alcoholic beverages during the past 12 months.

“Drug Abuse” refers to (1) the use of prescribed or over the counter drugs in excess of the directions, and (2) any nonmedical use of drugs.

The various classes of drugs may include cannabis (marijuana, hashish), (solvents (e.g.speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin), solvents, tranquilizers (e.g., heroin). Remember that the questions do not include alcoholic beverages or tobacco.

Please anwser every question. If you have difficulty with a statement, then choose the response that is mostly right.
1. Have you used drugs other than those required for medical reasons?*
2. Do you abuse more than one drug at a time?*
3. Are you always able to stop using drugs when you want to? (if never us drugs, answer "Yes."*
4. Have you had "blackouts" or "flashbacks" as a result of drug use?*
5. Do you ever feel bad or guilty about your drug use? If never use drugs, choose "No."*
6. Does your spouse (or parents) ever complain about your involvement with drugs?*
7. Have you neglected your family because of your use of drugs?*
8. Have you engaged in illegal activities in order to obtain drugs?*
9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?*
10. Have you had medical problems as a result of your drug use )e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?*

REGISTRATION FORM

CLIENT INFORMATION

CLIENT/PATIENT ACKNOWLEDGMENT & CONSENT TO TREAT

Solvista

Solvista Health

Drug Abuse Screen Test. DAT-10

PCL SHORT