Pathways Mental Health Services
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      • Outpatient Services
      • Group Therapy
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  • Therapy Interest Form
  • Online Testing & Screening
  • Patient Portal

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.
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Additional crisis resources
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
Demographic Form
 ​
Notice of Privacy Act - Read only
(For your records; 
Do Not Return to Pathways)
Insurance & Financial Form 

Insurance & Financial Form 
 
​​​Release of Information 
​
Optional; Complete if you would like us to communicate with anyone about your care.
MH Informed Consent 
MH Informed Consent 
 -
Acknowledgement of Privacy Act 
Acknowledgement of Privacy Act 
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Providers Addendum to the Informed Consent:
Licensed Providers

  1. Art Tolentino, PhD, LMFT, MAC, CDP, SAP
  2. ​
  3. Kelly Kimbel, MA, LMHC
  4. Mary Trukositz, MA, LMHC, CDP

  5. ​Patricia "Pat" Beck, MA, LMHC

  6. ​Lisa Hanna, MA, LMHC
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.

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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.
​
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COMPANY:
About Us
Employment

Pathways Staff
Pathways Providers
SUPPORT:
​Email: ​ PMHS Admin
​
Text:   360-777- 7284
​Phone:  360-799-5782
Toll Free: 888-617-6993
NEW PATIENT:
Insurance
Hours of operation
​
Reinstatement Form
​
Release of Information Form
​Informed Consent & HIPAA

Therapy Interest Form ​
OUR SERVICES:
DOT-SAP
LGBTQI Services

Mental Health

Trauma Treatment/EMDR
Intake & Wellness Program


TELEHEALTH:
​​Telehealth
Crisis Resources
TRAINING:
Mental Health First Response
OTHER:
Clinical Supervision
​
Internship Program
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  • Home
    • Staff
    • Providers
    • Satisfaction Survey
  • Olympia Clinic
  • Mental Health Counseling Services
    • Mental Health >
      • Outpatient Services
      • Group Therapy
    • Trauma Focused Treatment
    • DOT - SAP Services
  • Therapy Interest Form
  • Online Testing & Screening
  • Patient Portal