Lacey Clinic Fillable Forms
We cannot process your intake paperwork until we received all of the required forms and a copy of your insurance card and picture ID. You need to put your SIGNATURE on all of the required fillable forms
After completing the fillable forms, please fax a copy of your photo ID and insurance card to (360) 539-1715 for the Lacey Clinic.
Once we have all forms and have verified your insurance coverage, we will place your name on our wait list for an assessment appointment. Please be aware that the wait may be several weeks.
Notice: Due to Washington health care laws, the ROI form should be completed by clients age 13 and up if a parent or other party will need to communicate with us about scheduling or other information.
We do not provide crisis intervention services and do not place clients who are in crisis or having thoughts of suicide on our wait list. If you are having thoughts of suicide or seeking crisis services for other reasons, please call the Thurston County Crisis Line at 360-586-2800, go to the Emergency Room, or contact your insurance provider for a referral to local area crisis services.
1. Demographic Form - for all adult patients
TRICARE Subscriber number is the Beneficiary Number on the back of the military ID
2. Demographic Form - for all children & adolescents
3. Insurance & Financial Form - for all patients
4. MH Informed Consent - for all patients
5. Acknowledgement of Privacy Act - for all patients