• REGISTRATION FORM

    REGISTRATION FORM

  • If you need any help filling out this form, please contact us at (719) 275-2351

  • Solvista

  • Pronoun(s):
  • Birthdate*
     / /
  • Assigned Gender for insurance and legal purposes:*
  • Gender Identity:
  • Are you the client?*
  • Are you the Biological Parent?*
  • Are you the Legal Guardian?*
  • Is Physical Address the same as Mailing Address?*
  • Primary Phone #
  • Secondary Phone #
  • Is it okay to leave a message on the primary contact number?
  • Appointment Reminder Message Type:
  • Appointment preference:*
  • Do you have a primary care provider?*
  • Are you being referred by any of the following? Please mark all that apply and provide contact name:*
  • Would you like to sign a Release of information (ROI) to share information with any of the listed above? Please Choose one:
  • Employment Status:*
  • Marital Status*
  • Do you need an interpreter?
  • Ethnic Origin*
  • Race (check all that apply):*
  • Sexual Orientation:*
  • Are you pregnant?*
  • Highest Level of Education Completed*
  • Tobacco use status:*
  • Living in your home (mark all that apply):*
  • Are you homeless? :*
  • Have you ever served in the U.S. Military?*
  • Do you have an Advance Directive/Living Will?*

  • EMERGENCY CONTACT

  • Is the address the same as the client?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • INSURANCE INFORMATION:

  • Is the client covered by the insurance?*
  • Birthdate
     / /
  • Relationship to Policy holder:*
  • Is the policy holder address the same as the client?
  • Format: (000) 000-0000.

  • PAYMENT INFORMATION

  • Source:*
  • Source:
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  • I verify, by signing below, that the income noted is my verifiable household income and number of dependents. I may be asked to provide proof of income or benefits. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Solvista Health or insurance company to release any information required to process my claims. Falsification of information may result in disqualification of assistance.

  • Clear
  • Todays Date*
     / /
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  • 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.

  • 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.

    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.

  • 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.

  • 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.

  • Clear
  • Todays Date*
     / /

  • If you are the Parent/Guardian of the client/patient, please sign below

  • Clear
  • Todays Date
     / /

  • Solvista Health Adolescent screeners

  • PHQ-9 modified for Adolescents (PHQ-A)

  • Today's Date:*
     / /

  • Instructions: How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom put an "X" in the box beneath the answer that best describes how you have been feeling.

  • 1. Feeling down, depressed ,irritable, or hopeless?
  • 2. Little interest or pleasure in doing things?
  • 3. Trouble falling or staying asleep, or sleeping too much
  • 4. Poor appetite, weight loss or overeating?
  • 5. Feeling tired or having little energy?
  • 6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down.
  • 7. Trouble concentrating on things, such as reading thenewspaper 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 in some way?
  • In the PAST YEAR have you felt depressed or sad most days, even if you felt okay sometimes?
  • If you are experiencing any of the problems on this form, how DIFFCULT have these problems made it for you to do your work, take care of things at home or get along with other people
  • Has there been a time in the Past Month when you have had serious thoughts about ending your life?
  • Have you EVER in your WHOLE LIFE, tried to kill yourself or made suicide attempts?

  • " If you have had thoughts that you would be better off dead or hurting yourself in some way, please discuss this with your Health Care Clinician, go to a hospital emergency room, or call 911."

  • Modified with permission from the PHQ (Spitzer, Williams & Kroenke, 1999) by J. Johnson (Johnson, 2002)

    Phone: 719.275.2351 Fax: 719.269.9386

    3225 Independence Rd., Cañon City, CO 81212

  • The CRAFFT Questionnaire (version 2.0)

    Please answer all questions honestly: your answers will be kept confidential.

    During the PAST 12 MONTHS, on how many days did you:

  • READ THESE INSTRUCTIONS BEFORE CONTINUING:

    • If you put "0" in ALL of the boxes above, ANSWER QUESTION 4, THEN STOP.
    • If you put "1" or higher in ANY of the boxes above, ANSWER QUESTIONS 4-9.

     

  • 4. Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs?
  • 5. Do you ever use alcohol or drugs to RELAX, feel better about yourself. or fit in?
  • Do you ever use alcohol or drugs while you are by yourself. or ALONE?
  • 7. Do you ever FORGET things you did while using alcohol or drugs?
  • 8. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?
  • 9. Have you ever got into TROUBLE while you were using alcohol or drugs?

  • The information an this project is protected by special festional confidentiality rules 142 CFR Part 2k attach prohibit disclosure of this information understand without try specific written concent A general authorization for release of medical information is NOT NOTICE TO CLINIC STAfF AND MEDICAL RECORDS:

    @John R. Knight MO. Boston Children's Hospital 2016. forAddlescentPhone: 719.275.2351 Fax: 719.269.9386

    3225 Independence Rd. Cañon City CO 81212 Phone:719.275.2351 Fax:719.269.9386

    SolvistaHealth.org

  • PCL-SHORT

  • The next questions are about problems and complaints that people sometimes have in response to stressful life experiences. Please indicate how much you have been bothered by each problem in the past

     

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  • Authorization to Share Private Health Information

    I allow Solvista Health to share, use and exchange past, present and future health and personal information and I understand:

    • This Authorization is voluntary, and by my signature I affirm I have read, understand and agree to sign this Authorization.

    • This Authorization is valid the duration of treatment unless I revoke this Authorization or unless an earlier date is specified.

    • I may cancel this Authorization at any time to stop further communications except as needed for payment/operations.

    • Once my information is disclosed it may no longer be protected by federal and state privacy laws and could be re-disclosed; 42 CFR Part 2 and HIPAA prohibits unauthorized disclosure of certain records.

    • The medical information released may contain information related to HIV/AIDS, sexually transmitted diseases, mental health, drug/alcohol/substance use disorder, test results, treatment plans, etc.

    • The private/personal information released may include involvement with other community partners, DHS, courts, etc.

    • Copies of this form can be used instead of the original and Solvista may accept electronic or faxed signatures; a copy of this release is available upon request; a reasonable fee may be charged for copies of the record.

    • Psychotherapy notes are maintained separately and may not be released.

  • I allow information to be shared between Solvista Health and past, current and/or future provider, entity or individual(s):

  • INFORMATION TO BE SHARED (please pick one):
  • Entire Record EXCEPT I do NOT want the following information shared:
  • Release ONLY the following:
  • REASON FOR USE:*
  • Clear
  • Today's Date:*
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  • Clear
  • Today's Date
     - -

  • Please return to Solvista at 3225 Independence Road, Canon City, CO 81212; Phone: 719-275-2351; Fax: (719)269-9386

     

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