Patient Forms

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About
Services
Impact
AmeriCorps
Donate
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For your convinience our forms can be filled out online, simply click the links below. You can complete these patient forms in advance from the confort of your home, or complete at check-in.

Patient Forms

If you are interested in VOLUNTEERING, please CONTACT US to get started.

4338 W. Thomas Rd. Phx AZ 85031

Hours of Operation:

Monday – Thursday: 9 am – 6 pm Fridays by appointment

Call or Text

623-288-WVHE (9843)

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Practice Policies

Combined Consents and Policies for HRSA Compliance (Web)

Consent to Treatment
Consent to Treatment (Cont)
HIPAA Notice of Privacy Practices
Patient Rights and Responsibilities
Practice Policies

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Consent to Treatment of Behavioral Health and Substance Use Services

Consent to Treatment of Behavioral Health and Substance Use Services

I understand that during treatment, I may need to discuss material of an upsetting nature to resolve problems. While I understand that treatment is not guaranteed to resolve all issues, I consent to actively participate in developing and implementing my individualized treatment plan.

Compliance with Treatment Plan:

I agree to consistent attendance and understand that frequent "no-shows" or late cancellations may result in termination of services or fees assessed to my account.
I am responsible for adhering to my prescribed treatment plan, and failure to do so may lead to discharge from services.

West Valley Health Equity has provided me with a copy of their clinic policies. I understand that I am responsible for reviewing these policies and fulfilling all care, financial, and administrative requirements.

By signing this agreement, I consent to receive behavioral health services, including medication management and/or psychotherapy. I understand that it is my responsibility to read the policies carefully and refer to them when needed.

Patient Information:

First Name *

Last Name *

Date of Birth *

Signature *

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Date *

If you are human, leave this field blank.

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Home
About
Impact
Services
Housing
Behavioral Health
Legal Help
AmeriCorps
Donate
Apply for Housing
Contact
Patient Forms

Home
About
Impact
Services
Housing
Behavioral Health
Legal Help
AmeriCorps
Donate
Apply for Housing
Contact
Patient Forms