Intake Forms Child — Spanish

Community Reach Center Intake Forms - Become a Patient - Woman holding pen signing agreement document

Bienvenido al llegar al centro de la comunidad! Su primera sesión con nosotros se llama una reunión "Nueva Entrada". Por favor, haga clic en  ¿Qué esperar  de entender lo que se llevará a cabo en esta reunión. Ofrecemos nuevas reuniones de admisión en base a ras de suelo, 5 días a la semana a partir de 8-3pm primer llegado, primer servido.

En preparación para su primera reunión de admisión con nosotros, por favor, tómese unos minutos para descargar y completar los formularios a continuación. Puede que le resulte más fácil completar estas formas en el hogar donde se tiene toda la información disponible. Sin embargo, si usted no es capaz de imprimir estos, formularios estarán disponibles cuando llegue a una de nuestras oficinas. La mayoría de los formularios están disponibles en Inglés y Español.

Por favor use una  tinta de color negro  pluma para completar el formulario y no llene la fecha en el formulario hasta que llegue a la ingesta.

 

Intake Fax Coversheet View PDF
FORMULARIO DE ADMISIÓN al Community Reach Center
información demográfica
View PDF
FORMULARIO FINANCIERO DEL CONSUMIDOR 
F página rimero completa totalmente sobre su información de seguro. 
Señal de que podemos divulgar información a su seguro y que se autoriza el pago. Sírvanse también proporcionar  una copia de su tarjeta de identificación y el seguro (frente y parte posterior). Lea cuidadosamente la segunda página y conservar para sus registros
View PDF
Declaración de ingresos
Pedimos sus ingresos familiares para determinar la cantidad que pagaría en una escala de precios, si usted no tiene seguro o si alguna vez perdido su seguro. Pedimos a todos que completar esto.
View PDF
Forma de Admision para servicos mentales 
Describe el motivo de su visita
View PDF
Historia Médica
información médica incluyendo sus medicamentos actuales y proveedor médico actual.
View PDF
We look forward to seeing you soon!

Intake Forms Adult—Spanish

Community Reach Center Intake Forms - Become a Patient - Woman holding pen signing agreement document

Bienvenido al llegar al centro de la comunidad! Su primera sesión con nosotros se llama una reunión "Nueva Entrada". Por favor, haga clic en  ¿Qué esperar  de entender lo que se llevará a cabo en esta reunión. Ofrecemos nuevas reuniones de admisión en base a ras de suelo, 5 días a la semana a partir de 8-3pm primer llegado, primer servido.

En preparación para su primera reunión de admisión con nosotros, por favor, tómese unos minutos para descargar y completar los formularios a continuación. Puede que le resulte más fácil completar estas formas en el hogar donde se tiene toda la información disponible. Sin embargo, si usted no es capaz de imprimir estos, formularios estarán disponibles cuando llegue a una de nuestras oficinas. La mayoría de los formularios están disponibles en Inglés y Español. Sírvanse también proporcionar una copia del DNI y tarjeta de seguro (frente y parte posterior de un seguro privado).

Por favor use una  tinta de color negro  pluma para completar el formulario y no llene la fecha en el formulario hasta que llegue a la ingesta.

 

Intake Fax Coversheet View PDF
FORMULARIO DE ADMISIÓN al Community Reach Center
información demográfica
View PDF
FORMULARIO FINANCIERO DEL CONSUMIDOR 
F página rimero completa totalmente sobre su información de seguro. 
Señal de que podemos divulgar información a su seguro y que se autoriza el pago. Sírvanse también proporcionar  una copia de su tarjeta de identificación y el seguro (frente y parte posterior). Lea cuidadosamente la segunda página y conservar para sus registros
View PDF
Declaración de ingresos
Pedimos sus ingresos familiares para determinar la cantidad que pagaría en una escala de precios, si usted no tiene seguro o si alguna vez perdido su seguro. Pedimos a todos que completar esto.
View PDF
Preguntas sobre el uso de drogas y alcohol
de detección de abuso de sustancias
View PDF
Forma de Admision para servicos mentales 
Describe el motivo de su visita
View PDF
Historia Médica
información médica incluyendo sus medicamentos actuales y proveedor médico actual.
View PDF
¡Esperamos verte pronto!

Intake Forms Child — English

Community Reach Center Intake Forms - Become a Patient - Woman holding pen signing agreement document

Welcome to Community Reach Center! Your first session with us is called a "New Admission" meeting. Please click on What to Expect to understand what will take place at this meeting. We offer new admission meetings on a walk-in basis, 5 days a week from 8-3pm first come, first serve.

In preparation for your first intake meeting with us, please take a few minutes to download and complete the forms below. You may find it easier to complete these forms at home where you have all your information available. However, if you are not able to print these, forms will be available when you arrive at one of our offices. Most forms are available in both English and Spanish. Please also provide a copy of your ID and insurance card (front and back for private insurance).

Please use a black ink pen to complete the form and do not fill in the date on the form until you arrive for intake.

 

Intake Fax Coversheet View PDF
Admission Form 
Demographic information
View PDF
Consumer Financial Form 
First page complete fully about your insurance information. 
Sign that we can release information to your insurance and you are authorizing payment. Please also provide a copy of your ID and insurance card (front and back). Carefully read the second page and keep for your records
View PDF
Proof of Income Form 
We ask for your household income to determine the amount you would pay on a sliding scale fee, if you do not have insurance or if you ever lost your insurance. We ask everyone to complete this.
View PDF
Brief Triage Form 
Describe the reason for your visit
View PDF
Medical History Form 
Medical information including your current medications and current medical provider.
View PDF
We look forward to seeing you soon!

Intake Forms Adult — English

Community Reach Center Intake Forms - Become a Patient - Woman holding pen signing agreement document

Welcome to Community Reach Center! Your first session with us is called a "New Admission" meeting. Please click on What to Expect to understand what will take place at this meeting. We offer new admission meetings on a walk-in basis, 5 days a week from 8-3pm first come, first serve.

In preparation for your first intake meeting with us, please take a few minutes to download and complete the forms below. You may find it easier to complete these forms at home where you have all your information available. However, if you are not able to print these, forms will be available when you arrive at one of our offices. Most forms are available in both English and Spanish. Please also provide a copy of your ID and insurance card (front and back for private insurance).

Please use a black ink pen to complete the form and do not fill in the date on the form until you arrive for intake.

 

Intake Fax Coversheet View PDF
Admission Form 
Demographic information
View PDF
Consumer Financial Form 
First page complete fully about your insurance information.
Sign that we can release information to your insurance and you are authorizing payment. Please also provide a copy of your ID and insurance card (front and back). Carefully read the second page and keep for your records
View PDF
Proof of Income Form 
We ask for your household income to determine the amount you would pay on a sliding scale fee, if you do not have insurance or if you ever lost your insurance. We ask everyone to complete this.
View PDF
Substance Use Screening 
Substance abuse screening
View PDF
Brief Triage Form 
Describe the reason for your visit
View PDF
Medical History Form 
Medical information including your current medications and current medical provider.
View PDF
We look forward to seeing you soon!

Parent Workshop: How to talk with your teen about substance use

The perfect workshop for parents or guardians committed to preventing
substance use in their teens and those currently facing this issue who want
to learn how to motivate and support behavioral change for their teen.

 

Mary Ciancio Memorial Building 

8989 Huron Street

Thornton, CO 80260

Monday evenings 5:30-7:00 pm

Facilitated by Michelle Dance, BA, Family Advocate

 

Weekly Topics

Why Communication & Family Involvement Works?

Self Care – Job#1

Problem Solving: Try and Experiment

Behaviors Make Sense… Even Your Child’s

Positive Reinforcement: Changing Behaviors with Honey

Natural Consequences

 

Workshop topics re-cycle every six weeks. You’re welcome to join the group at any time during the series!

Contact Michelle Dance 303.229.6599 | M.Dance@communityreachcenter.org

View or download our Parent Workshop Flyer

National Alliance on Mental Illness – Adams County (A-NAMI)

A-NAMI is a group of families, friends, and individuals living with mental illness whose mission is to improve the quality of life for persons with brain disorders and their families. A-NAMI  works to ensure dignity and non-discriminatory access to quality health care, housing, education, and employment.

A-NAMI hosts the monthly Friends & Family Support Group. Each meeting provides participants time for sharing challenges and triumphs related to their experience with mental illness, and an opportunity to give and receive emotional support. The Friends & Family Support Group meetings frequently feature presentations by mental health professionals and educational discussions. The Friends & Family Support Group believes persons who have a mental health challenge should not be discriminated against. We assist individuals in advocating for themselves, in order to allow them equal opportunity to do the things that bring meaning and purpose to all our lives.

When: Last Wednesday of every month, 7:00 to 9:00pm

Where: Community Reach Center
CRC Community Campus
1870 W. 122nd Ave | Westminster, CO  80234

(Meeting cancellations are rare but do occur.  Please contact Sheryl Bain, sbain60@gmail.com or 303-853-3770 to confirm the meeting that you plan to attend.)

MHFA Class Schedule

There is no registration fee for participants who live or work in Adams County, thanks to generous support from Community Reach Center Foundation Board.  Otherwise, there is a $35 registration fee. All participants MUST be registered  - drop-ins are not permitted.

 

Mental Health First Aid - Youth Module
(curriculum covers mental health issues among youth 12 to 18 years of age.)

 

March 24, 2017 | 8am to 5pm - CLICK HERE TO REGISTER

Community Reach Center

1870 W. 122nd Ave.

Westminster, CO 80234

 

April 7, 2017 | 8am to 5pm - CLICK HERE TO REGISTER

Community Reach Center

1870 W. 122nd Ave.

Westminster, CO 80234

 

Mental Health First Aid - Adult Module
(curriculum covers mental health issues among adults)

March 10, 2017 | 8am to 5pm - CLICK HERE TO REGISTER

Community Reach Center

1870 W. 122nd Ave.

Westminster, CO 80234

 

April 28, 2017 | 8am to 5pm - CLICK HERE TO REGISTER

Community Reach Center

1870 W. 122nd Ave.

Westminster, CO 80234

Financial FAQ

Q. When is payment due for my therapy sessions or groups?
A. Payment, including insurance co-payments, is expected at the time of intake and at each appointment. We accept Visa, MasterCard, checks, and cash.


 

Q. What insurance do we accept?

A. We are providers for Medicaid, Medicare, and several other insurance companies. Insurance providers that we regularly work with include the following:

  • Blue Cross/Blue Shield
  • Kaiser (must have referral from Kaiser)
  • Tricare Standard (must have a referral in prescription form from your Primary Care Provider)
  • United Behavioral Plans (selected plans - please check with your insurance provider)
  • Medicaid
  • Medicare
  • CHP+
  • The Medicaid Buy-In Program for Children with Disabilities (Children’s Buy-In) is a Family Medical Assistance program that provides Medicaid benefits for children with disabilities whose adjusted family income is at or below 300% of the Federal Poverty Level (FPL). Eligible families receive Medicaid benefits for their child with a disability by paying a monthly premium on a sliding scale based on their adjusted income. The Children’s Buy-In is for children under age 19 who have a qualifying disability, and whose adjusted family income is at or below 300% of the Federal Poverty Level (FPL). Click here for complete details.

If you have another insurance provider, please check with that company to see if they will authorize service from the Community Reach Center. Co-payments and deductibles can vary by insurance provider and policy; these fees will be discussed at your initial meeting.

Most insurance companies require pre-authorization, so be sure to call your insurance company before coming to your initial appointment with us and bring your insurance card.


 

Q. What if I have no insurance?

A. You may qualify for a reduced fee or grant based on your specific circumstances and household income. The fee will be determined at your first meeting with us. Please complete the Client Income Form found in the Intake Forms section and bring the requested proof of income. Please note that the State of Colorado requires us to consider income from all sources (salaries, support payments, investments, public assistance, etc.) for all persons living in the household, whether or not they are related. For this reason, it will be helpful for you to examine and complete the Client Income Form before your first meeting.

VALE Grant funding for psychotherapy and psychiatric services is available to residents of the 17th Judicial District who have been victims of crimes. Services could include individual, family and/or group therapy, as well as psychiatric assessments tailored to meet each client's specific needs. Services are offered at no cost to crime victims.


 

Q. If I am unable to come to one of my appointments, will I need to pay for that appointment?

A. As with most medical appointments, you are asked to cancel appointments 24 hours in advance. If you do not cancel your appointment, you may be charged a fee by your insurance provider.


 

Q. Whom do I call if I have a question about my bill?

A. Please call our main phone number at (303) 853-3500, and simply ask for "Billing."