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Participant Registration Form - Signing a Contract



Please note that children under 18 must be accompanied by a legal guardian. Adults with guardians must obtain written consent from the legal guardian prior to being served. (Please provide a copy of guardianship papers for Adults).

Is this your legal name?
Marital Status
Leave a Message?
Preferred Language
Legal Guardian?
Legal Guardian Relationship
Highest Education
Living Arrangement
Military Service
Military Branch
Is this person already a patient of Amara?
Income Source


Is this patient covered by insurance?
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Insurance Carrier Name
Is the Responsible Party Employed?
Patient's Relationship to Subscriber


Do you have a Behavioral Health need and are you here today for Medication only?
Are you currently receiving services from another agency?
Have you been hospitalized within the last 90 days?
Are you currently experiencing any of the following symptoms; (check all that apply)
Have you used drugs in the last 24 hours (including marijuana)?
Have you used alcohol in the last 24 hours?
Any history of hospitalization due to mental health problems?
Have you been hospitalized within the past 6 months?
Within the past year?
Are you here for a court ordered mental health evaluation?


Do you have a primary care health provider?
Do you have any of the following Medical Diagnoses? (Check all that apply)
Past head or brain injury?
Are you experiencing any of the following “health related” issues:


How did you hear about AWS or who referred you?

I understand that AWS, Inc. has a Med Clinic to offer Medication Management services for their Medicaid and non-Medicaid participants. This information has been discussed with me and I have made the following choice. I have chosen AWS, Inc. to provide the services to me that have been marked with a check. These services are listed below.

Participant Choice:

I understand and consent to these treatment services and that I may stop treatment services at any time. I also understand that I may refuse to take medication and/or revoke consent at any time. This authorization is to remain in effect for one year or until revoked in writing. My signature below indicates that I have read and understand this consent/choice form.

Thanks for submitting!

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