Faculty and Staff Mental Health Clinic Intake Form

Faculty and Staff Mental Health Clinic Intake Form

All appointment information for your telehealth or in-person visits are uploaded to the secure patient portal, My Health Connection. Please download the My Health Connection app to your desktop and/or phone. Faculty and Staff Mental Health accepts most insurances, including CU Anthem, CU GME sponsored plan, and Denver Health Medical Plan. We highly encourage you to please check with your insurance provider concerning coverage/terms limitations (i.e., co-pays, deductible, number of visits, etc.). Your health is important to us and during these challenging times, it’s important to stay connected. Faculty Staff Mental Health will be in contact with you within the next 48 business hours.

If you need immediate care, please call 911 or go to your nearest emergency care center or you can contact the Colorado Crisis Service Line at 844-493-8255.

Please select the following employee/student classification that you identify with the most*

Please complete this form instead. Thank you

Which department do you work in?*

Tell us about you

Legal last name*

Legal first name*

Is there another name that you go by?*

Select

If yes, what is that name?

Date of Birth*

Gender Identity*

Select

Ethnicity*

Select or enter value

Race*

Select

We also need some demographic information please

Street Address*

City, State, Zip*

Contact Information

Contact Telephone*

Phone

Email Address*

Preferred method of communication?*

Select

Is it okay for the clinic to leave messages?*

Select

When is your preferred time for a FSMHC staff member to contact you?*

When is your preferred time for a FSMH staff member to contact you?*

Select

What type of treatment are you interested in?*

Select

How did you find out about our clinic?*

Select

If you selected other, where did you hear about our clinic?*

Additional Patient Information

What is the first and last name of your emergency contact?*

What is their best contact telephone number?*

What is their relationship to you?*

Do you currently have a primary care physician (PCP)?*

Yes

What is the name of your primary care physician?*

What is the contact telephone number of your primary care physician?*

Payment/Insurance Information

Would you like to pay out of pocket or use your insurance?*

Select

Who is the guarantor for your care?*

Who is the person that carries the responsibility to pay any charges that are billed for treatment services?

Select

What is the legal full name of the guarantor?*

Relationship of guarantor to patient?*

Is the home address the same as the patient?*

Select

Guarantor Address*

Guarantor City/State/ZIP*

Guarantor phone*

Phone

Who is the subscriber/policy holder of your insurance?*

Select

What is the subscriber's name?*

What is the subscriber's date of birth?*

Is the subscriber's address the same as yours?*

Yes

What is the address of the subscriber for your insurance policy?*

Please include city, state and ZIP code.

Subscriber Phone*

Phone

Is there anything you would like for the clinic to know?

Please upload a copy of your insurance card (front/back)*

Drag and drop files here or

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