Mountain West Behavioral Health

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can.

Limited to 600 characters

Have you seen a mental health professional before?

Yes No Other

Specify all medications and supplements you are currently taking, including dosages.

Limited to 600 characters

If taking prescription medication, who is your prescribing doctor?

Were you court-ordered to attend therapy? If so, who is requiring it?

Are you currently on probation? If so, what is the name of your probation officer?

How would you prefer we contact you about billing questions or payment arrangements?

Phone Call Text Email

Billing & Payment

Payment method

How do you plan to pay?

Please list the name of your insurance carrier or EAP program you plan on utilizing. "

If paying out of pocket or unsure, please write "N/A

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

I understand that Mountain West Behavioral Health does not accept Medicare, Dual-Enrollment Plans (Medicare/Medicaid), Tricare, or Molina and acknowledge that I understand I am responsible for the full cost of services if I have these types of insurance.

Yes

Client Preferences

Is there a specific clinician you'd prefer to see?

Is there anything else you'd like us to know about you?

If there is nothing else you'd like to add, please write "N/A"

Limited to 600 characters

Administrative

Driver's license upload

Do not upload sensitive financial information such as credit card information.

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.