RFI Test

WAIVER TO RELEASE APPLICATION STATUS

I hereby authorize Four Winds Behavioral Health to release information regarding my application status. This authorization
of release includes my application approval, estimated wait time, program acceptance, and intake for the purpose of aiding, collaboration and coordination of services.
I authorize the following people to obtain my application status:

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

Telehealth Terms of Treatment

To comply with current safety restrictions related to COVID 19, Four Winds Behavioral Health (FWBH) utilizes a combination of telehealth and in-person services to provide Addiction and Mental Health Treatment.

FWBH is taking the necessary steps to create a safe, supportive experience that complies with HIPPA privacy laws.

Please read the following:

• Must have use of a video/audio capable device that is charged or plugged in (Smartphone, tablet, or computer)
• Must have internet access with a stable Wi-Fi connection
• Must be in a well-lit, quiet, and private location (HIPPA requirement)
• Should be logged into the session 5 minutes before the session start time
• Must be on time to be considered present for the session
• Telehealth is an audio and video communication which requires discretion with appearance, location, and dress.

REQUIRED: CHOOSE AN OPTION

Yes, I understand and I am able to engage in services via telehealth.

Yes, I understand but I am NOT able to engage in services via telehealth. I also understand this may delay my ability to receive services. I will contact FWBH immediately if this changes.

Contact scheduling at 505-702-8547 immediately regarding changes to your contact information (Phone number or email address). Always leave EITHER, a voicemail or email [email protected] and [email protected] with any changes.

Redisclosure: I understand that Four Winds Behavioral Health cannot guarantee that the recipient will not disclose my application status to a third party.

I understand that I can revoke my waiver at any time and for any reason. I understand that my Authorization will automatically expire one year from the date of my signature unless I request it be revoked earlier (see below).

By signing below, I certify all information is true and correct to the best of my ability and grant permission for
Four Winds Behavioral Health to contact Probation/Parole/Court Officer if necessary.
In case of an emergency, FWBH has my authorization to notify my Emergency Contact.
"By submitting this application, I acknowledge that a staff member of this facility may be calling to ask follow up questions or communicate my application status. I authorize any staff member of the facility to call and identify themselves as calling from the facility to speak to me."

Signature:

Please only click submit one time.

REQUEST FOR SERVICES

Applicant Information

Referring Agency

Emergency Contact

Reason For Seeking Treatment

Medical Insurance

Criminal Offense History

Are you required to register as a sex offender?

Have you been convicted of a felony?

Have you been convicted of a misdemeanor?

Do you currently have any pending charges?

Have you or are you currently affiliated with any gang related activity?

Advanced Directives: (Check all that apply)

APPROVED AND PROHIBITED ITEMS

Approved Items Allowed Upon Intake

Starter Kit (Must be brought within 36 Hours of Admission)

Non-Approved Items

Medical History

Can you walk up and down stairs?

Are you diabetic? Do you require a special diet?

Do you currently have any major medical conditions?

Are you currently taking any medications?

Do you have any medication allergies and adverse reactions:

Do you have any current psychiatric and/or medical medications

What is the highest level of education you have completed?

Were you ever diagnosed with a learning disability?

Have you ever worked with a mental health provider?

Do you require an Oxygen tank?

Do you have HEPC?

Are you currently under going treatment for HEPC?

Current Weight:

Do you know when your last visit to a primary care physician was:

On what date was your last visit with your primary care physician?

Have you ever been hospitalized?

Have you or are you being treated for any of the following or are you currently having symptoms related to any of the following?

Please explain for each box you checked

PSYCHIATRIC HISTORY

Personal psychiatric history (Check all that apply):

Please explain each box you checked above

WAIVER TO RELEASE APPLICATION STATUS

Telehealth Terms of Treatment

Redisclosure: I understand that Four Winds Behavioral Health cannot guarantee that the recipient will not disclose my application status to a third party.

I understand that I can revoke my waiver at any time and for any reason. I understand that my Authorization will automatically expire one year from the date of my signature unless I request it be revoked earlier (see below).

Mission Statement

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