Mental Health Registration

Mental Health Registration

Welcome to the YWCA Contra Costa/Sacramento Mental Health Program.

The YWCA Contra Costa/Sacramento takes seriously our obligation to safeguard your personal information. We understand that medical information about you is personal, and we are dedicated to maintaining the privacy of your data. Please read carefully the information provided in step 2 of your registration; it will explain your rights regarding how your data can be used or disclosed.

With the intention of making the best use of your time, we ask you to please fill out the forms in the list below before your first appointment; the entire process will take 30 to 45 minutes to complete. If a question on any of the forms does not apply, please enter N/A or None.

For clients who have completed all forms for a child before their first onsite appointment, the child will have an opportunity to pick out an item from our Treasure Chest in the office.

Registration Phases

Step 1

Registration Form – If you are an adult and you are filling out this form out for a child, please remember all information requested is about the child, fill in all spaces or mark N/A if the information requested is not applicable, it will take 20 to 30 minutes to complete. Once you complete this form, you will then be redirected Step 2.

Step 2

Once you have completed the Registration Form, you can now move on to completing the “Mental Health Registration Package” which consists of the following forms that need to be read, signed and dated. It will take you 5 to 10 minutes to complete each form. Once you complete one form, you will then be redirected to the next form on the list. If a question on any of the forms does not apply, please enter N/A, None or leave it blank if it is not a required field.

  • Release of Information: This form will allow your clinician to speak with other providers or concerned parties which you designate. Please sign & date. Do not fill out any other spaces, your therapist will call for information when needed.
  • Office Policies and General Information: This form requires a signature and date
  • Consent to Use Or Disclose Information for Privacy Practices: Read, sign and date this form.
  • HIPAA Notice of Privacy Practices and Acknowledgement: Read, sign and date the acknowledgment.
  • Consent for Video or Audio Taping: Video or audio taping a session can be a helpful tool for some consumers, but will never be used without your permission. Please sign and date.
  • Mental Health Consumer Grievance Procedures and Acknowledgement: Read this document, sign and date at the end.

Proceed to the Mental Health Registration Package Step 1

Medi-Cal Coverage Only

Dear Consumer,



In our waiting rooms we have the Medi-Cal Beneficiary Handbook which contains basic information about Medi-Cal. We also have the following forms available in English and Spanish for your convenience:

 

  • Provider Directory
  • Consumer Grievance Review Request Form
  • Consumer Request for Change of Provider Form
  • Advance Directive
  • Appeal or Expedited Appeal Request Form
  • Consumer Suggestion Form

 

Thank you, once again for your interest and participation in the YWCA Contra Costa/Sacramento mental health program, we look forward to serving you. If you have any questions or concerns, please feel free to contact Lynne at 925-372-4213 x 116 or your clinician.



If you would like a copy of the completed forms, please contact Lynne at 925-372-4213 x 116 to have one provided to you at your first appointment.



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