Student and Resident 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. Please be advised that all appointments will be billed directly to your insurance. Please be aware of your insurance plan and/or benefits, including deductibles, copays or coinsurance. You can find this information by calling the number on the back of your insurance card and asking for your Behavioral Health benefits for Outpatient Services or going to your insurance's website. Students who are covered through the Anthem Student Advantage Plan will have no copay or costs associated with their visit when seen within the SRMH Clinic. Your mental health is very important to us and during these challenging times, it is important to stay connected. Student and Resident Mental Health Staff will be in contact with you within the next 1-3 days.


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 classification that is the most accurate*
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Tell us about you

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We also need some demographic information please

Contact Information

Phone
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Additional Patient Information

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

Clinical Information

Have you been seen in our clinic before?*
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Is this visit for an Intern/Resident/Fellow Opt-Out Wellness Program?*

Payment/Insurance Information

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

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

Please include city, state and ZIP code.

Phone
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