Consent To Treat Contract
Financial Responsibility Agreement
Client Medical Release / Emergency Information Form
CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION SUBSTANCE ABUSE PROGRAM, MEDICAID, FIRST HEALTH SERVICE CORPORATION, AND STATE OF ALASKA DHSS DIVISION OF BEHAVIORAL HEALTH
CONTACT PREFERENCES
Client Notice
Client Profile
Demographics
Intake Information
1. File Location: Where will client be admitted? (To be filled out by Staff)
2. Intake Staff (To be filled out by Staff)
5. Intake Date (To be filled out by Staff)
Collateral Contacts
Life Domains/Client Status
3. Client Type (To be filled out by Staff)
Life Domains/Education
Life Domains/Financial/Household Information
Life Domains/Financial/Household Information (Continued)
Life Domains/Substance Abuse Information
Life Domains/Legal Status