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Canyon Pines Counseling, PLLC

19563 E Mainstreet Ste 200
Parker, CO 80138
(303) 475-2323

PRIMARY CLIENT INFORMATION

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PARTNER INFO

Second client Registration

PRIMARY INSURED

Insurance Self Pay EAP Third Party

May we call at work? YesNo

Primary Insurance Information

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SECONDARY INSURED ("If Applicable")

May we call at work? YesNo

Secondary Insurance Information

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Terms And Conditions

Hi,

In order to get started with services with our office please complete the online registration.  Please make sure you complete all forms within this link for your registration.  If you have questions or difficulty with any of the forms please let your therapist know and they can assist you.

HIPAA
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HIPAA

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%3cdiv contenteditable%3d%27false%27 unselectable%3d%27on%27 class%3d%27unselectable%27%3e%3cp style%3d%22text-align%3a center%3b%22%3e%3cstrong%3eHIPAA FORM%3c/strong%3e%3cbr%3e%3c/p%3e%3cp%3e%26nbsp%3b%3c/p%3e%3cp%3eNOTICE OF PRIVACY POLICIES AND PRACTICES%3cbr%3eTHIS NOTICE DESCRIBES HOW MEDICAL AND MENTAL HEALTH INFORMATION ABOUT YOU%3cbr%3eMAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.%3cbr%3ePLEASE REVIEW IT CAREFULLY%3cbr%3eGiven the nature of Canyon Pines Counseling PLLC %28“CPC”%29’s work%2c it is imperative that it maintains the%3cbr%3econfidence of client information that it receives in the course of its work. CPC is a mental health practice that%3cbr%3eprovides mental health services. CPC’s practice works solely to provide the best counseling treatment options to its%3cbr%3eclients. CPC is prohibited from releasing any client information to anyone outside immediate staff%2c employees%2c%3cbr%3einterns%2c and/or volunteers except in limited circumstances in accordance with this Notice of Privacy Policies and%3cbr%3ePractices. Discussions or disclosures of protected health information %28“PHI”%29 within the practice are limited to the%3cbr%3eminimum necessary that is needed for the recipient of the information to perform his/her job. Please review this%3cbr%3eNotice of Privacy Policies and Practices %28“Notice of Privacy Policies”%29. It is my policy to%3a%3cbr%3e1. fully comply with the requirements of the HIPAA General Administrative Requirements%2c the Privacy and%3cbr%3eSecurity Rules%3b%3cbr%3e2. provide every client who receives services with a copy of this Notice of Privacy Policies%3b%3cbr%3e3. ask the client to acknowledge receipt when given a copy of this Notice of Privacy Policies%3b%3cbr%3e4. ensure the confidentiality of all client records transmitted by facsimile%3b%3cbr%3e5. obtain from each client an informed Authorization for Release of Protected Health Information form when%3cbr%3erequired.%3cbr%3eCPC is required to follow all state and federal statutes and regulations including Federal Regulation 42 C.F.R. Part 2%3cbr%3eand Title 25%2c Article 4%2c Part 14 and Title 25%2c Article 1%2c Part 1%2c CRS and the Health Insurance Portability and%3cbr%3eAccountability Act %28HIPAA%29%2c 45 C.F.R. Parts 142%2c 160%2c 162 and 164%2c governing testing for and reporting of TB%2c%3cbr%3eHIV AIDS%2c Hepatitis%2c and other infectious diseases%2c and maintaining the confidentiality of PHI.%3cbr%3ePHI refers to any information that I create or receive%2c and relates to an individual’s past%2c present%2c or future physical%3cbr%3eor mental health or conditions and related care services or the past%2c present%2c or future payment for the provision of%3cbr%3ehealth care to an individual%3b and identifies the individual or there is a reasonable basis to believe the information can%3cbr%3ebe used to identify the individual.PHI includes any such information described above that I transmit or maintain in%3cbr%3eany form%2c this includes Psychotherapy Notes. HIPAA and federal law regulate the use and disclosure of PHI when%3cbr%3etransmitted electronically.%3cbr%3e%3cbr%3eYOUR RIGHTS AS A CLIENT%3a%3cbr%3eWhen it comes to your health information%2c you have certain rights. This section explains your rights and some%3cbr%3eof our responsibilities to help you.%3cbr%3eGet an electronic or paper copy of your mental health record%3cbr%3e• You can ask to see or get an electronic or paper copy of your mental health record and other health%3cbr%3einformation we have about you. Ask us how to do this.%3cbr%3e• We will provide a copy or a summary of your health information%2c usually within 30 days of your request.%3cbr%3eWe may charge a reasonable%2c cost-based fee to fulfill your request.%3cbr%3e• If we deny your request%2c in whole or in part%2c we will let you know why in writing and whether you have the%3cbr%3eoption of having the decision reviewed by an independent third-party.%3cbr%3eAsk us to correct your mental health record%3cbr%3e• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us%3cbr%3ehow to do this.%3cbr%3e• We may say “no” to your request%2c but we’ll tell you why in writing within 60 days.%3cbr%3eRequest confidential communications%3cbr%3e• You can ask us to contact you in a specific way %28for example%2c home or office phone%29 or to send mail to a%3cbr%3edifferent address.%3cbr%3e• We will say “yes” to all reasonable requests.%3cbr%3e• Please review the Consent For Communication Of Protected Health Information By Non-Secure%3cbr%3eTransmissions%3cbr%3e• You are required to “opt-in” to receive communications electronically as set-forth in the Consent for%3cbr%3eCommunication of Protected Health Information by Non-Secure Transmissions. If you choose not to%3cbr%3e“opt-in” to receive electronic communications%2c we will not communicate with you via electronic means.%3cbr%3eAsk us to limit what we use or share%3cbr%3e• You can ask us not to use or share certain health information for treatment%2c payment%2c or our operations. We%3cbr%3eare not required to agree to your request%2c and we may say “no” if it would affect your care.%3cbr%3e• If you pay for a service or health care item out-of-pocket in full%2c you can ask us not to share that%3cbr%3einformation for the purpose of payment or our operations with your health insurer. We will say “yes” unless%3cbr%3ea law requires us to share that information.%3cbr%3eAdditional Restrictions%3cbr%3e• You have the right to request additional restrictions on the use or disclosure of your mental health%3cbr%3einformation. However%2c we do not have to agree to that request%2c and there are certain limits to any%3cbr%3erestriction. Ask us if you would like to make a request for any restriction%28s%29.%3cbr%3eGet a list of those with whom we’ve shared information%3cbr%3e• You can ask for a list %28accounting%29 of the times we’ve shared your health information for six years prior to%3cbr%3ethe date you ask%2c who we shared it with%2c and why.%3cbr%3e• We will include all the disclosures except for those about treatment%2c payment%2c and health care operations%2c%3cbr%3eand certain other disclosures %28such as any you asked us to make%29. We’ll provide one accounting a year for%3cbr%3efree but will charge a reasonable%2c cost-based fee if you ask for another one within 12 months.%3cbr%3eGet a copy of this privacy notice%3cbr%3e• You can ask for a paper copy of this notice at any time%2c even if you have agreed to receive the notice%3cbr%3eelectronically. We will provide you with a paper copy promptly.%3cbr%3eChoose someone to act for you%3cbr%3e• If you have given someone medical power of attorney or if someone is your legal guardian%2c that person can%3cbr%3eexercise your rights and make choices about your health information.%3cbr%3e• We will make sure the person has this authority and can act for you before we take any action.%3cbr%3e%3cbr%3eFile a complaint if you feel your rights are violated%3cbr%3e• You can complain if you feel we have violated your rights by contacting us using the information on page%3cbr%3e• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights%3cbr%3eby sending a letter to 200 Independence Avenue%2c S.W.%2c Washington%2c D.C. 20201%2c calling 1-877-696-6775%2c%3cbr%3eor visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.%3cbr%3e• We will not retaliate against you for filing a complaint.%3cbr%3e• You may also file a complaint with the Colorado Department of Regulatory Agencies%2c Division of%3cbr%3eProfessions and Occupations%2c Mental Health Section%3b 1560 Broadway%2c Suite 1350%2c Denver%2c Colorado%2c%3cbr%3e80202%2c 303-894-2291%3b DORA_Mentalhealthboard@state.co.us . Please note that the Department of%3cbr%3eRegulatory Agencies may direct you to file your complaint with the U.S. Department of Health and Human%3cbr%3eServices Office for Civil Rights listed above and may not be able to take any action on your behalf.%3cbr%3eUSES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION%3cbr%3eA use of PHI occurs within a covered entity %28i.e.%2c discussions among staff regarding treatment%29. A disclosure of PHI%3cbr%3eoccurs when CPC reveal PHI to an outside party %28i.e.%2c CPC provides another treatment provider with PHI%2c or shares%3cbr%3ePHI with a third party pursuant to a client’s valid written authorization%29.%3cbr%3eCPC may use and disclose PHI%2c without an individual’s written authorization%2c for the following purposes%3a%3cbr%3e1. Treatment%3a disclosing and using your PHI by those who are involved in your care for the purpose of%3cbr%3eproviding%2c coordinating%2c or managing your health care treatment and related services. This includes%3cbr%3econsultation with clinical supervisors or other treatment team members and for coverage arrangements%3cbr%3eduring your therapist’s absence%2c and for sending appointment reminders or information about treatment%3cbr%3ealternatives or other health-related benefits and services that may be of interest to you.%3cbr%3e2. Payment%3a disclosing and using your PHI so that CPC can receive payment for the treatment services%3cbr%3eprovided to you%2c such as%3a making a determination of eligibility or coverage for insurance benefits%2c%3cbr%3eprocessing claims with your insurance company%2c reviewing services provided to you to determine medical%3cbr%3enecessity%2c or undertaking utilization of review activities.%3cbr%3e3. Health Care Operations%3a disclosing and using your PHI to support CPC’s business operations which may%3cbr%3einclude but not be limited to%3a quality assessment activities%2c licensing%2c audits%2c and other business activities.%3cbr%3eUses and disclosures for payment and health care operations purposes are subject to the minimum necessary%3cbr%3erequirement. This means that CPC may only use or disclose the minimum amount of PHI necessary for the purpose%3cbr%3eof the use or disclosure %28i.e.%2c for billing purposes CPC would not need to disclose a client’s entire medical record in%3cbr%3eorder to receive reimbursement. CPC would likely only need to include a service code and/or diagnosis etc.%29. Uses%3cbr%3eand disclosures for treatment purposes are not subject to the minimum necessary requirement.%3cbr%3eCPC is required to promptly notify you of any breach that may have occurred and/or that may have compromised%3cbr%3ethe privacy or security of your PHI.%3cbr%3eConfidentiality of client records and substance abuse client records maintained are protected by federal law and%3cbr%3eregulations. It is CPC’s policy that a client must complete an Authorization for Release of Protected Health%3cbr%3eInformation it provides prior to disclosing health information to another individual and/or entity for any purpose%2c%3cbr%3eexcept for treatment%2c payment%2c or health care operations in accordance with this Notice of Privacy Policies.%3cbr%3e%3cbr%3eAbsent the above referenced form%2c other than for treatment%2c payment%2c or health care operations purposes%2c CPC is%3cbr%3eprohibited from disclosing or using any PHI outside of or within the organization%2c including disclosing that the client%3cbr%3eis in treatment without written authorization%2c unless one of the following exceptions arises%3a%3cbr%3e1. Responding to lawsuit and legal actions %28Disclosure by a court order%2c in response to a complaint filed%3cbr%3eagainst CPC%2c etc. This does not include a request by you or another party for your records%29.%3cbr%3e2. Disclosure is made to medical personnel in a medical emergency or to qualified personnel for research%2c%3cbr%3eaudit or program evaluation.%3cbr%3e3. Help with public health and safety issues %28Client commits or threatens to commit a crime either at%3cbr%3eCPC’s office or against any person who works for CPC%3b A minor or elderly client reports having been%3cbr%3eabused or there is reasonable suspicion that abuse has or will take place%3b Client is planning to harm%3cbr%3eanother person%2c including but not limited to the harm of a child or at-risk elder%3b Client is imminently%3cbr%3edangerous to self or others%29.%3cbr%3e4. Address workers’ compensation%2c law enforcement%2c and other government requests.%3cbr%3e5. Respond to organ and tissue donation requests.%3cbr%3e6. Business Associates%3a CPC may enter into contracts with business associates to provide billing%2c legal%2c%3cbr%3eauditing%2c and practice management services that are outside entities. In those situations%2c protected%3cbr%3ehealth information will be provided to those contractors as is needed to perform their contracted tasks.%3cbr%3eBusiness associates are required to enter into an agreement maintaining the privacy of the protected%3cbr%3ehealth information released to them.%3cbr%3e7. In compliance with other state and/or federal laws and regulations.%3cbr%3eThe above exceptions are subject to several requirements under the Privacy Rule%2c including the minimum necessary%3cbr%3erequirement and applicable federal and state laws and regulations. See 45 C.F.R. § 164.512. Before using or%3cbr%3edisclosing PHI for one of the above exceptions%2c CPC’s staff must consult its Privacy Officer %28Jennifer Worcester%2c%3cbr%3ePsyD%2c LPC%2c 303-475-2323%2c jennifer@canyonpinescounseling.com %29 to ensure compliance with the Privacy Rule.%3cbr%3eViolation of these federal and state guidelines is a crime carrying both criminal and monetary penalties. Suspected%3cbr%3eviolations may be reported to appropriate authorities%2c as listed above in the “Client Rights” section%2c in accordance%3cbr%3ewith federal and state regulations. Know that CPC will never market or sell your personal information without your%3cbr%3epermission.%3cbr%3eSPECIAL AUTHORIZATIONS%3cbr%3eCertain categories of information have extra protections by law%2c and thus require special written authorizations for%3cbr%3edisclosures.%3cbr%3ePsychotherapy Notes%3a CPC may keep and maintain “Psychotherapy Notes”%2c which may include but are not limited%3cbr%3eto notes CPC makes about your conversation during a private%2c group%2c joint%2c or family counseling session%2c which is%3cbr%3ekept separately from the rest of your record. These notes are given a greater degree of protection than PHI. These are%3cbr%3enot considered part of your “client record.” CPC will obtain a special authorization before releasing your%3cbr%3ePsychotherapy Notes.%3cbr%3eHIV Information%3a Special legal protections apply to HIV/AIDS related information. CPC will obtain a special%3cbr%3ewritten authorization from you before releasing information related to HIV/AIDS.%3cbr%3e%3cbr%3eAlcohol and Drug Use Information%3a Special legal protections apply to information related to alcohol and drug use%3cbr%3eand treatment. CPC will obtain a special written authorization from you before releasing information related to%3cbr%3ealcohol and/or drug use/treatment.%3cbr%3eYou may revoke all such authorizations to release information %28PHI%2c Psychotherapy Notes%2c HIV information%2c and/or%3cbr%3eAlcohol and Drug Use Information%29 at any time%2c provided each revocation is in writing%2c signed by you%2c and signed%3cbr%3eby a witness. You may not revoke an authorization to the extent that %281%29 CPC has relied on that authorization%3b or %282%29%3cbr%3eif the authorization was obtained as a condition of obtaining insurance coverage%2c the law provides the insurer the%3cbr%3eright to contest the claim under the policy.%3cbr%3eAs a covered entity under the Privacy and Security Rules%2c CPC is required to reasonably safeguard PHI from%3cbr%3eimpermissible uses and disclosures. Safeguards may include%2c but are not limited to the following%3a%3cbr%3e1. Not leaving test results unattended where third parties without a need to know can view them.%3cbr%3e2. Any PHI received as an employee%2c intern%2c or volunteer about a client or potential client%2c may not be used or%3cbr%3edisclosed for non-work purposes or with unauthorized individuals. CPC may only use and disclose such PHI%3cbr%3eas described above.%3cbr%3e3. When speaking with a client about his or her PHI where third parties could possibly overhear%2c the conversation%3cbr%3ewill be moved to a private area.%3cbr%3e4. Seeking legal counsel in uncertain situations and/or incidences.%3cbr%3e5. Obtaining a Business Associates Agreement with those third-parties that have access to and/or store client%3cbr%3einformation. Some of the functions of the practice may be provided by contracts with business associates. For%3cbr%3eexample%2c some of the billing%2c legal%2c auditing%2c and practice management services may be provided by%3cbr%3econtracting with outside entities to perform those services.%3cbr%3e6. Implementing FAX security measures%3cbr%3e7. Obtaining your consent prior to sending any PHI by unsecure electronic transmissions%3cbr%3e8. Providing information on my electronic record-keeping.%3cbr%3eYOUR CHOICES%3a%3cbr%3eFor certain health information%2c you can tell CPC %28verbal authorization%29 your choices about what it shares. If%3cbr%3eyou have a clear preference for how CPC shares your information in the situations described below%2c talk to CPC.%3cbr%3eTell CPC what you want it to do%2c and it will follow your instructions. CPC may request you sign a separate%3cbr%3edocument if you authorize it to share certain PHI. You may revoke that authorization at anytime for future%3cbr%3edisclosure.%3cbr%3eIn these cases%2c you have both the right and choice to tell CPC to%3a%3cbr%3e• Share information with your family%2c close friends%2c or others involved in your care%3cbr%3e• Share information in a disaster relief situation%3cbr%3e• Include your information in a hospital directory%3cbr%3eIf you are not able to tell CPC your preference%2c for example if you are unconscious%2c CPC may go ahead and share%3cbr%3eyour information if CPC believes it is in your best interest and for your care/treatment. CPC may also share your%3cbr%3einformation when needed to lessen a serious and imminent threat to public health or safety.%3cbr%3eIn these cases we never share your information unless you give us written permission%3a%3cbr%3e• Marketing purposes%3cbr%3e• Sale of your information%3cbr%3e• Most sharing of psychotherapy notes%3cbr%3e%3cbr%3eChanges to the Terms of this Notice%3cbr%3eCPC can change the terms of this notice%2c and the changes will apply to all information CPC has about you. The new%3cbr%3enotice will be available upon request%2c in CPC’s office%2c and on its web site.%3cbr%3eThis notice is effective %3cinput type%3d%22text%22 style%3d%22width%3a 100px%3b height%3a 22px%3b%22%3e%3cbr%3e_____________________________________ ____________________%3cbr%3eClient Signature Date%3cbr%3eFor more information see%3a www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html%3cbr%3e%3c/p%3e%3c/div%3e

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Canyon Pines Counseling, PLLC

19563 E Mainstreet Ste 200
Parker, CO 80138
(303) 475-2323

Intake

1. How did you hear about us?

2. What type of therapy are you seeking? Individual Couples Family Hybrid

3. What brings you in?

4. What would your partner say?

5. Length of these relationship:

6. Can you tell me a little bit about yourself and your family/culture/upbringing?

7. Can you tell me a little bit about what intimate relationships look like for you?

8. Do you have any dependents?

9. Therapy before:

10. Psychiatry before:

11. Medications (type & dosage frequency):

12. Alcohol and Drug Use (type & dosage frequency):

Describe use:

13. Marijuana/Cannabis products: Yes No

Do you have a medical marijuana card? Yes No

Describe use:

14. Recreational drugs: Yes No

Describe use:

15. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

16. Self Harming Behaviours: Yes No

Describe, including most recent incident:

17. Violence Towards Others: Yes No

Describe, including most recent incident:

18. Physical/Emotional/Sexual abuse in the past: Yes No

Describe:

19. Experience of life being threatened by person, accident, or natural disaster: Yes No

20. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

21. Actions taken concerning above risks:

22. Religious Affiliation/Denomination:

23. Occupation:

24. Preferred Location:

25. School: (grade/year, graduation date & current GPA):

26. City Year Employee: (site name, site grade level, & program manager):

27. Availability:

28. Clinician assigned:

29. Initial Appointment:

30. Client Informed of Fee: Insurance and/or Sliding scale amount:

31. Client Informed of 2 business day cancellation policy: Yes No

32. Who did the intake:

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Canyon Pines Counseling, PLLC

19563 E Mainstreet Ste 200
Parker, CO 80138
(303) 475-2323

Intake

1. Occupation:

Youth worker:

No describe

Yes describe

2. If City Year Employee: (site name, site grade level, & program manager):

3. How did you hear about us?

4. What type of therapy are you seeking? Individual Couples Family Hybrid Group

5. What brings you in?

6. Client stated strengths

7. Can you tell me a little bit about yourself and your family/culture/upbringing?

8. Tell me a little bit about your community & social supports

9. Do you have any dependents?

10. Therapy before:

11. Psychiatry before:

12. Medications (type & dosage frequency):

13. Alcohol and Drug Use (type & dosage frequency):

Describe use:

14. Marijuana/Cannabis products: Yes No

Do you have a medical marijuana card? Yes No

Describe use:

15. Recreational drugs: Yes No

Describe use:

16. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

Access to any weapons, if so type:

17. Self Harming Behaviours: Yes No

Describe, including most recent incident:

18. Violence Towards Others: Yes No

Describe, including most recent incident:

19. Physical/Emotional/Sexual abuse in the past: Yes No

Describe:

20. Experience of life being threatened by: Person Accident Natural Disaster

21. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

22. Actions taken concerning above risks:

23. Religious Affiliation/Denomination:

24. Preferred Location:

25. School: (grade/year, graduation date & current GPA):

26. Availability:

27.Insurance and/or Sliding scale amount:

Everything below is for Office Staff Only to Complete

28. Clinician assigned:

29. Initial Appointment:

30. Client Informed of Fee:

31. Client Informed of 2 business day cancellation policy: Yes No

32. Who did the intake:

32. Youth worker: Yes No

33. Describe if not occupation (under occupation)

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Canyon Pines Counseling, PLLC

19563 E Mainstreet Ste 200
Parker, CO 80138
(303) 475-2323

Intake

1. How did you hear about us?

2. What type of therapy are you seeking? Individual Couples Family Hybrid

3. What brings you in?

4. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

5. Violence Towards Others: Yes No

Describe, including most recent incident:

6. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

7. Client Informed of Fee: Insurance and/or Sliding scale amount:

8.Client Notes

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Canyon Pines Counseling, PLLC

19563 E Mainstreet Ste 200
Parker, CO 80138
(303) 475-2323

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Secure Site

Canyon Pines Counseling, PLLC

19563 E Mainstreet Ste 200
Parker, CO 80138
(303) 475-2323

Intake

Intake Question

Referral Source

Are you currently on active duty? Yes No

Military Branch

Highest Level of Education

Employment status

Are you currently enrolled in school or job training program?

Are you currently using? Yes No

Routine of administration types:

During the past 30 days, how many days have you used any of the following:

Cocaine/crack

Marijuana/Hashish

Heroine

Morphine

Dilaudid

Demerol

Fentanyl

Percocet

Darvon

Codeine

Tylenol 2, 3, 4

OxyContin/Oxycodone

Non-prescription methadone

Hallucinogens/psychedelics, PCP, LSD, Mushrooms, or Mescaline

Methamphetamine or other amphetamines

During the past 30 days, how many days have you used any of the following:

Benzodiazepines: diazepam, alprazolam, Triazolam, and etizolam

Barbiturates: Metharbital and pentobarbital sodium

Non-prescription GHB

Ketamine

Other tranquilizers, downers sedatives, or hypnotic

Inhalants

Other illegal drugs

Drug of Choice-Diagnosis

Behavioral Health

Children's Services Referral Yes No

If Children's Services referral, do you have an active Children's Services case? Yes No

# of children that you have

Crime Justus status

Probation Yes No

Parole Yes No

PROB 45 Yes No

Human Trafficking

Is there a history of Sexual Abuse?

Program Placement (Level of Care)

Sober Housing Needed Yes No

Sober Housing Provided Yes No

Medical Intake Questions

If female, are you pregnant? Yes No

Medicated Assisted Treatment (MAT)

Hypertension

Diabetes

STI's

UTI's

Cellulitis

COPD

Asthma

Blood dyscrasia

City

State

Zip code

County

Is there a history of drug use? Yes No

In the past 30 days, where have you been living most of the time?

Are you currently employed?

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Notes

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Card Type:

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Canyon Pines Counseling, PLLC

19563 E Mainstreet Ste 200Parker, CO 80138(303) 475-2323

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Canyon Pines Counseling, PLLC

19563 E Mainstreet Ste 200Parker, CO 80138(303) 475-2323

Canyon Pines Counseling, PLLC

19563 E Mainstreet Ste 200Parker, CO 80138(303) 475-2323

Canyon Pines Counseling, PLLC

19563 E Mainstreet Ste 200Parker, CO 80138(303) 475-2323

Canyon Pines Counseling, PLLC

19563 E Mainstreet Ste 200Parker, CO 80138(303) 475-2323

Canyon Pines Counseling, PLLC

19563 E Mainstreet Ste 200Parker, CO 80138(303) 475-2323

19563 E Mainstreet Ste 200
Parker, CO 80138
(303) 475-2323

19563 E Mainstreet Ste 200
Parker, CO 80138
(303) 475-2323

19563 E Mainstreet Ste 200
Parker, CO 80138
(303) 475-2323

19563 E Mainstreet Ste 200
Parker, CO 80138
(303) 475-2323

19563 E Mainstreet Ste 200
Parker, CO 80138
(303) 475-2323

19563 E Mainstreet Ste 200
Parker, CO 80138
(303) 475-2323