ANTHC Behavioral Health Wellness Clinic New Client Registration Form Step 1 of 13 – New Client Registration 0% New Client RegistrationAre you Alaska Native or American Indian?(Required)Are you Alaska Native or American Indian and receive care at ANMC or any Tribal facility in Alaska? Yes No Unsure Please call the BHWC at 907-729-BHWC (2492) or 1 (833) 642-BHWC (2492).The BHWC only serves Tribal Health beneficiaries at this time. Check with your insurance provider or call 211 to learn about behavioral health resources that may be available to you. New Client RegistrationAre you 18 years old or older?(Required) Yes No The BHWC services are open to individuals who are 18 years of older. For support identifying services available to those under 18 years of age, please call the BHWC at 1-907-729-2492 or 1-833-642-2492.Are you currently in Alaska?(Required) Yes No Due to regulations, we are only able to serve adults who are currently in Alaska. Please call us at 1-907-729-2492 or 1-833-642-2492 to discuss options for accessing services in your area.Do you have access to computer or phone and a reliable internet connection?(Required) Yes No The BHWC is a 100% telehealth clinic. A computer or phone with internet connection or a phone is needed for accessing BHWC appointments. Please call us at 1-907-729-2492 or 1-833-642-2492 to discuss options for accessing our services.Do you need an interpreter/translator for your appointment?(Required) Yes No What language would you like an interpreter for? Client InformationAre you completing this form for yourself?(Required) Yes No Are you completing this form as someone’s court appointed legal guardian?(Required) Yes No Upon completion of this form, you will be required to provide a copy of the court order.Legal Guardian Name(Required) First Last Legal Guardian Date of Birth(Required) Month Day Year Legal Guardian Phone(Required)Relationship to patient(Required) Mother Father Grandmother Grandfather Legal Guardian Other Please upload a copy of the court order. Drop files here or Select files Accepted file types: jpeg, png, pdf, gif, Max. file size: 8 MB. Please call the BHWC at 1-907-729-2492 or 1-833-642-2492 to complete the registration forms over the phone. Client InformationFirst Name(Required) Last Name(Required) Date of Birth(Required) Month Day Year Last 4 digits of Social Security Number(Required) PronounsFor example: he, she, they Gender(Required) Female Male Nonbinary Choose not to disclose Other Do you identify as transgender? Yes No Choose not to disclose What is your race?(Required) American Indian or Alaska Native Asian Black or African American Native Hawaiian Pacific Islander White Choose not to disclose Other Other(Required) What is your ethnicity?(Required) Not Hispanic or Latino Hispanic or Latino Unknown Choose not to disclose Are you a veteran?(Required) Yes No Contact InformationEmail(Required) Enter Email Confirm Email Phone(Required)May we call you back on this phone to complete the registration process?(Required) Yes No What time of day is best for us to call you to complete the initial screening? The initial screening phone call completes the registration process and will take about 30 minutes.Our clinic is open from 8 am-5 pm Monday through Thursday and 8 am-4 pm on Friday. Morning (8 am-11 am) Lunchtime (11 am-1 pm) Afternoon (1 pm-5 pm) Other If there is a specific time you need, please let us know and we will do our best to call you at that preferred time.(Required) After you complete the New Cient Registration forms, please call the BHWC at 907-729-2492 or 1-833-642-2492 at your convenience to complete your intake and schedule an appointment. Our clinic is open Monday through Thursday from 8 am-5 pm, and Friday 8 am-4 pm.Are you currently experiencing homelessness? Yes No Physical Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Health BenefitsWhich benefits plan(s) do you currently have?(Required)Check all that apply. Medicaid Medicare Private Insurance IHS/Tribal health beneficiary None Medicaid Policy Number Medicare Policy Number Enter private insurance information(Required) Policy number Group number Would you like to meet with a staff person to explore health benefit options available to you? Yes No Please upload a picture of the front and back side of your health benefits card. Drop files here or Select files Accepted file types: jpeg, jpg, pdf, png, Max. file size: 8 MB. Health and Wellness InformationWhat brings you to the ANTHC Behavioral Health Wellness Clinic? Please check all that apply.(Required)I am here for: Overall health and wellness. Stress, anxiety, or depression. Acute stress and trauma. Grief and loss. Alcohol and/or drug use. Substance use assessment. I am not sure. Another option not listed here. Another option not listed here How did you hear about us? Professional Referral Search (Google, Bing, etc.) Word of Mouth (family, friend, etc.) Social Media (Facebook, Instagram, etc.) Community Event 988 Lifeline Other Notice of Privacy PracticesIf you have questions about our Notice of Privacy Practices, please call the BHWC at 1-907-729-2492 or 1-833-642-2492. A copy of the Notice of Privacy Practices is also available on our website Unable to display PDF file. Download instead. Notice of Privacy Practice(Required) I acknowledge that I have received a copy of the Notice of Privacy Practices.(Required) Assignment of BenefitsIf you have questions about our Assignment of Benefits, please call the BHWC at 1-907-729-2492 or 1-833-642-2492. A copy of the Assignment of Benefits is also available on our website. Unable to display PDF file. Download instead. Assignment of Benefits(Required) I agree to the Assignment of Benefits(Required) Client Rights and ResponsibilitiesIf you have questions about our Client Rights and Responsibilities, please call the BHWC at 1-907-729-2492 or 1-833-642-2492. A copy of the Client Rights and Responsibilities is also available on our website. Unable to display PDF file. Download instead. Client Rights and Responsibilities(Required) I acknowledge that I have received a copy of the Client Rights and Responsibilities.(Required) Telehealth Informed ConsentIf you have questions about our Telehealth Informed Consent, please call the BHWC at 1-907-729-2492 or 1-833-642-2492. A copy of the Telehealth Informed Consent is also available on our website Unable to display PDF file. Download instead. Telehealth Informed Consent(Required) I consent to receive BHWC telehealth services.(Required) The BHWC sends appointment confirmations, reminders, and links to clients over text message or email. Do you consent to receive appointment confirmations, reminders, and links over text message or email? Standard text messaging charges may apply.(Required) Yes No The BHWC is a telehealth clinic and consenting to text and email appointment confirmations, reminders, and links is a requirement for accessing care. Please call us at 1-907-729-2492 or 1-833-642-2492 to discuss your options. I agree that the information provided is accurate and consent that the BHWC may contact me to complete my intake to start services.NameThis field is for validation purposes and should be left unchanged.
