Lacey Clinic Fillable Forms:
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.
REQUIRED FORMS Adult Patients |
REQUIRED FORMS Children & Adolescents |
OPTIONAL FORMS |
Demographic Form TRICARE Subscriber number is the Beneficiary Number on the back of the military ID |
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Release of Information Optional; Complete if you would like us to communicate with anyone about your care. |
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Providers Addendum to the Informed Consent:
Licensed Providers
Clinical Intern
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.
