New Group Client Intake

Estimated time to complete : 5-10 minutes

Congratulations in taking steps towards a healthier existence, and towards getting the support you need. Moving towards improvement begins with us getting to know your needs and your wants. The better we understand you, the better we can help you.

The Group Intake Process

Once you have completed this intake form and our office staff have set up your health chart, we will contact you to set up the in-person portion of the intake.

Insurance Benefits Information

Most groups are paid by self-pay either because they are not covered by insurance or the provider running the group may not accept your specific insurance. Please complete the insurance sections of this form so that our staff have your information on hand if there is a possibility that you are able to make use of your insurance.

Confidentiality Of Submitted Form Information

Any information submitted using the form below will be encrypted before it is transmitted to our offices, where it is securely stored according to HIPAA regulations. Your confidential information is sent to us directly and is not stored unencrypted at any point in any thrid-party services or hosts.

Do not resubmit this form

Do not submit multiple versions of this form for the same client. We have only one profile per client and multiple intake submissions will all be put on-hold until admin staff have time to manually determine which version is the most accurate and therefore WILL significantly hold up your intake process. If you have previously submitted incorrect information please call or email to update, giving your name and date and time of your submission.

For Yourself Or Another Person?

Are you filling this out for someone else who will be receiving services?

Note: In Washington state, children over the age of 13 are legally allowed to engage in their own self-directed mental health treatment without parental consent. (See Chapter 71.34 RCW) However, we fully encourage the participation of parents in their child's care.

Ok, for this is for someone else. For our records, what is your name (not client)? *

What is your relationship to this other person? *

Okay, great, you are filling out this form for someone else. Please now answer the rest of the form as the client (their birthdate, insurance, etc).

What Group Are You Interested In?

What are you interested in? *

We Need To Know Some Details About You

First name *

Any middle initial

Last name *

Your phone *

Your email *

Note: An email address is required. The nature of email communication means confidentiality can not be guaranteed.

Your address (street) *

Your address (suite)

Your address (city) *

Your address (state) *

Your address (zipcode or postcode) *

Your address (country) *

Date of birth of person wanting services *

Month

Day

Year

This person identifies as a gender different from their legal gender

You identify as

What are your preferred pronouns (if any)?

Use Insurance If Possible?

We cannot guarantee that any group or workshop will be covered by insurance. If insurance coverage is not available then you will be required to pay the cost of the groups or workshops.

Will you be using insurance for payment? *

Yes

Do you have Medicare? *

Yes

NOTICE : We do not accept Medicare insurance. Even if you also have a commercial insurance as secondary, we cannot accept your insurance (primary insurance must be billed). You may continue but please be aware that you will need to pay cash for your appointments.

Is this insurance provided by EAP? *

EAP (Employee Assistance Program) is a voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems.

Yes

Please upload an image of the front of your insurance card

If you are using a smart phone you can take a photo and upload here. Alternatively, if you have access to a scanner you can scan and upload.
Files must be less than 8 MB.
Allowed file types: gif jpg jpeg png bmp tif psd pdf.

Please upload an image of the back of your insurance card

Primary Insurance Provider *

Name of other primary insurance *

Do you have a Medicaid plan? (such as Washington Apple Health) *

Yes

Are you the insurance's primary policy holder?

Yes

Name of the primary insured person? *

Date of birth of primary insured person *

Month

Day

Year

Gender of the primary insured person *

Enter the person's gender. If this is incorrect then your insurance claims will be denied and you will be responsible for the full amount due.

What is the primary insured person's current address? *

Please put the address on a SINGLE line eg. '123 Some St, Cityscape, WA'

What is the primary insurance ID? *

You will find this on your insurance card

What is the primary group ID?

Will you be using secondary insurance?

Yes

Secondary Insurance Provider *

Name of other secondary insurance *

Name of the secondary insured person? *

Date of birth of secondary insured person *

Month

Day

Year

Gender of the secondary insured person *

Enter the person's gender. If this is incorrect then your insurance claims will be denied and you will be responsible for the full amount due.

What is the secondary insured person's current address? *

Please put the address on a SINGLE line eg. '123 Some St, Cityscape, WA'

What is the secondary insurance ID? *

What is the secondary group ID?

KAISER CORE HMO

IMPORTANT!

Kaiser Core HMO has a specific requirement that, prior to your session, you MUST call them to have your session pre-authorized or they will deny your claim and you will be responsible for the full session fee. The call should take only a few minutes to complete. The number to call is;

1 - 888 - 901 - 4636

A Little About You

If you are currently seeing a mental health counselor, please give their name here

Have you ever had suicidal thoughts? *

If you are feeling suicidal right now, have a plan or intent, please call

911

or go to your

nearest hospital

If you have been feeling generally suicidal, but have no specific plan, please call the national crisis suicide helpline

1-800-273-8255

or you can also chat online

Suicide Chatline

Suicidal feelings are not uncommon and can be difficult to handle in the moment, but as bad as you might feel, it is important to remember that like any feelings, those moments will pass and feelings will go. Suicidal feelings are temporary ways that your mind lets you know you need help. We will help you towards understanding these feelings, reducing the intensity, and working towards healing growth. Making an appointment with us is a great first step in dealing with these feelings, but remember that we can only meet with you at your scheduled appointments and we are not your first port of call when these feelings become too much for you. It is essential that you call 911 or the crisis line as appropriate when you start to feel suicidal, and important that you keep your scheduled appointments with us and tell us about your feelings during your session.

Have you ever made suicidal attempts? *

Have you ever had hospitalization for mental health related issues? *

Have you ever had visual or auditory hallucination? *

Have you ever been involved in legal proceedings for perpetrating violence? *

Have you ever been listed on any sex offender registry? *

Your Goals

Groups and workshops are activities that result in changes such as growth, insight and healing, as well as being fun and shared events. Although the group or workshop already has an established goal, setting a personal intention to achieve something specific helps in making that a reality and can improve your chances of getting what you want from your investment in yourself. It may be as specific as "I want to learn skills that will help me remain calm in times of workplace stress" or as vague as "I want to learn whatever comes to me during the process".

Tell us a little about what you hope to achieve from attending this group/workshop?

How did you hear about our services?

Help us discover the most effective ways to reach you. With your help, the funds we would have spent on ineffective marketing can instead be spent on improving services.

I found King Health Associates through

What is their name?

Where did you see or find it?

What keywords did you use to find us?

You MUST click the continue button below to proceed. The form may take a few seconds to process - please do not click multiple times.

New Group Client Intake

The Group Intake Process

Insurance Benefits Information

Confidentiality Of Submitted Form Information

Do not resubmit this form

For Yourself Or Another Person?

What Group Are You Interested In?

We Need To Know Some Details About You

Use Insurance If Possible?

KAISER CORE HMO

IMPORTANT!

1 - 888 - 901 - 4636

A Little About You

Your Goals

How did you hear about our services?

Clinic News

Quick Contact

Quick Links

Crisis Numbers

By Telephone

Via Online chat

By Text