Pathways Mental Health Services

Mental Health &
​telemedicine Forms 

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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.
Child & Adolescent Demographic Form
File Size: 594 kb
File Type: pdf
Download File

Adult Demographic Form
File Size: 588 kb
File Type: pdf
Download File

Informed Consent
File Size: 375 kb
File Type: pdf
Download File

HIPAA & Privacy Act
File Size: 318 kb
File Type: pdf
Download File


Optional Form​:
Release of Information.pdf
File Size: 579 kb
File Type: pdf
Download File

Providers Addendum to the Informed Consent:

licensed providers

  1. Art Tolentino, PhD, LMFT, MAC, CDP, SAP
  2. Loretta Crawford, MA, LMHC
  3. Kelly Kimbel, MA, LMHC
  4. Mary Trukositz, MA, LMHC, CDP
  5. Douglas Gemmell, MA, LMHC
  6. David Moeglein, MSW,  LICSW
  7. ​Patricia  "Pat" Beck, MA, LMHC
  8. ​Kris Vegvari, MA, LMHC, MAC
  9. ​Lisa Hanna, MA, LMHC
  10. Abby Smith, MA, LMHC
  11. Judith Oliver, MA, LMHCA
  12. Patrick Maley, MA, LMHCA
  13. Daniel Barash, MA, LMHCA
  14. ​Cherry Foultner, MA, LMFTA
clinical interns
  1. Cecilia Miller
  2. 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.
​

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  • Home
    • Staff
    • Providers
    • Satisfaction Survey
  • Clinics
    • Lacey Clinic
    • Longview Clinic
    • Telehealth Clinic
    • Telehealth International
  • Mental Health Counseling Services
    • Co-occurring Disorders Treatment >
      • Co-occurring Disorders Group
    • Mental Health >
      • Outpatient Services
      • Group Therapy
      • Play Therapy
    • Trauma Focused Treatment
  • Addiction Services
    • DOT - SAP Services
    • Outpatient Services
    • Relapse Prevention Therapy
    • Gambling Services
  • Insurance
    • Accepted Insurance
    • Accepted EAP
  • Online Testing & Screening
  • Training
  • Patient Portal
  • Therapy Interest Form
  • School Services