Benteh Wellness Center - Intake Form

Benteh Wellness Center

New Participant Intake Form

All applicable fields are required. Missing information may delay referral process. Please contact Benteh Wellness Center at 907-671-6871 with any questions.

Today's Date

Person Filling in This Form:

First name:

Last name:

Referring Agency:

Or Self

Contact Email:

PARTICIPANTS INFORMATION

Name:

Email Address:

Date of Birth:

Month

Day

Year

Age:

Sex:

Male

Female

Other

If other, what?

Phone Number:

Social Security Number:

Preferred Pronouns:

Race:

Alaskan Native/American Indian

Other

If other, what?

Tribal Affiliation:

Parent Name:

Parent Phone Number:

Custody %:

Parent Name:

Parent Phone Number:

Custody %:

Emergency Contact:

Contact Phone #:

Relationship:

REQUIRED BY THE STATE OF ALASKA

Is the participant pregnant?

Yes

No

Is the participant using injectable drugs?

Yes

No

If yes to being pregnant AND using injectable drugs, please contact 907-671-6863 immediately.

LIVING ARRANGEMENTS

If other, please explain:

Mailing Address:

Mailing Address

Country/Region

Address

City

Zip / Postal code

OCS Involvement:

Yes

No

Legal Guardian:

Probation Officer:

REASON FOR TREATMENT

In your own words, describe the participant in need of mental health services. Please describe specific behaviors the participant is exhibiting:

Reason for Treatment:

Where do these behaviors usually occur:

Home

School

Community

TREATMENT HISTORY

Is the participant currently receiving or has ever received Behavioral Health Services and/or Substance Abuse Treatment or support?

Yes

No

If so, where?

When?

Is the participant currently taking medications?

Yes

No

If yes, what medications?

Physician Name:

ADDITIONAL INFORMATION

Does the participant need special assistance to attend their appointment?

Yes

No

If yes, please describe:

Preference for Therapy:

Male

Female

First Available

Current School:

PAYMENT INFORMATION

Single choice:

MEDICAD

Other

Other:

Insurance ID #:

Subscriber Name:

Subscriber DOB:

Subscriber SSN:

Download Form

Download Handbook

Contact Us

Email: info@kniktribe.org
Tel: 907-373-7991
ICWA Fax: 907-373-2153
Main Fax: 907-373-2178
Admin Fax: 907-373-2161

Physical Address
1744 North Prospect
Palmer, AK 99645

Mailing Address
PO Box 871565
Wasilla, AK 99687