Pathways Mental Health Services

Telehealth forms

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Required Telemedicine/Telehealth Forms:  Printable

Pathways Clinic Telehealth Patient Printable Forms:
​1. Demographic Form -  Required for all Adult patients
2. Demographic Form -  All  Adolescent (13 year old and above)
​3. Insurance & Financial Form - Required for all patients.
4. Credit Card Authorization Form - Required for all patients.

5. MH Informed Consent - Required for all patients.
​6. Acknowledgement of Privacy Act - Required for all patients.
7. Telemedicine/Telehealth Informed Consent



​Mid-Valley Clinic ​Telehealth Patient Printable Forms:
​1. Demographic Form -  Required for all Adult patients
2. Demographic Form -  All  Adolescent (13 year old and above)
​3. Insurance & Financial Form - Required for all patients.
4. Credit Card Authorization Form - Required for all patients.

5. MH Informed Consent - Required for all patients.
​6. Acknowledgement of Privacy Act - Required for all patients.
7. Telehealth Informed Consent: Mid-Valley Clinic. 
OTHER Forms:
​1. Release of Information Form - Optional; Complete if you would like us to communicate with anyone about your care.
​2. 
Audio/Video Consent Form - Play Therapy only (Required for 6 to 12 year old)

Providers Addendum to the Informed Consent:

Licensed Providers
  1. Art Tolentino, PhD, LMFT, MAC, CDP, SAP
  2. Loretta Crawford, MA, LMHC
  3. Kaj Kayij-Wint, LMFT, PhD Candidate
  4. Kelly Kimbel, MA, LMHC
  5. Mary Trokositz, MA, LMHC, CDP
  6. Mary Coacher, MA, LMHC
  7. Douglas Gemmell, MA, LMHC
  8. David Moeglein, MSW,  LICSW
  9. Patricia "Pat" Beck, MA, LMHC
  10. Kris Vegvari, MA, LMHC, MAC
  11. Lisa Hanna, MA, LMHC


Clinical Interns
  1. Pat Malley
  2. Cherry Foultner

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) 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.
​

back to non fillable forms
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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