Required Forms - Printable
Please complete the 3 forms (Child & Adolescent or Adult demographic, Informed Consent and HIPAA & Privacy Act form) below in order to become a new patient of Pathways MHS or Pathways Wellness Program.
Please complete the 3 forms (Child & Adolescent or Adult demographic, Informed Consent and HIPAA & Privacy Act form) below in order to become a new patient of Pathways MHS or Pathways Wellness Program.
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| Informed Consent |
| HIPAA & Privacy Act |
Optional Form:
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Providers Addendum to the Informed Consent:
licensed providers
- Art Tolentino, PhD, LMFT, MAC, CDP, SAP
- Loretta Crawford, MA, LMHC
- Kelly Kimbel, MA, LMHC
- Mary Trukositz, MA, LMHC, CDP
- Douglas Gemmell, MA, LMHC
- David Moeglein, MSW, LICSW
- Patricia "Pat" Beck, MA, LMHC
- Kris Vegvari, MA, LMHC, MAC
- Lisa Hanna, MA, LMHC
- Abby Smith, MA, LMHC
- Judith Oliver, MA, LMHCA
- Patrick Maley, MA, LMHCA
- Daniel Barash, MA, LMHCA
- Cherry Foultner, MA, LMFTA
clinical interns
- Cecilia Miller
- Katie Parker
We cannot process your intake paperwork until we received all of the required forms and a copy of your insurance card and picture ID.
Please fax all the required forms and a copy of your photo ID and insurance card to (360) 539-1715 in Lacey or to (360) 846-1722 in Longview. Please do not email insurance cards or other confidential information as email is not a secure method of transmission. Once we have all forms and have verified your insurance coverage, we will call you to schedule an initial assessment.
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.
