To comply with current safety restrictions related to COVID 19, Four Winds Behavioral Health (FWBH) utilizes a combination of telehealth and in-person services to provide Addiction and Mental Health Treatment.
FWBH is taking the necessary steps to create a safe, supportive experience that complies with HIPPA privacy laws.
Please read the following:
• Must have use of a video/audio capable device that is charged or plugged in (Smartphone, tablet, or computer)
• Must have internet access with a stable Wi-Fi connection
• Must be in a well-lit, quiet, and private location (HIPPA requirement)
• Should be logged into the session 5 minutes before the session start time
• Must be on time to be considered present for the session
• Telehealth is an audio and video communication which requires discretion with appearance, location, and dress.
REQUIRED: CHOOSE AN OPTION
Or
Contact scheduling at 505-313-7055 immediately regarding changes to your contact information (Phone number or email address). Always leave BOTH, a message AND email
[email protected] with any changes.
Redisclosure: I understand that Four Winds Behavioral Health cannot guarantee that the recipient will not disclose my application status to a third party.
I understand that I can revoke my waiver at any time and for any reason. I understand that my Authorization will automatically expire one year from the date of my signature unless I request it be revoked earlier (see below).
By signing below, I certify all information is true and correct to the best of my ability and grant permission for
Four Winds Behavioral Health to contact Probation/Parole/Court Officer if necessary.
In case of an emergency, FWBH has my authorization to notify my Emergency Contact.
"By submitting this application, I acknowledge that a staff member of this facility may be calling to ask follow up questions or communicate my application status. I authorize any staff member of the facility to call and identify themselves as calling from the facility to speak to me."
