Online Request for Services

This is a non-emergency request for services. Requests will be processed Monday-Friday during normal business hours. For urgent service requests please call 800-562-3277.

If you are experiencing a life-threatening situation please call 911 or immediately go to an emergency room. If you are experiencing suicidal thoughts, homicidal thoughts or domestic violence please call the National Suicide and Crisis Lifeline at 988.

Please complete the following questionnaire to request non-emergency services.

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Caller Information
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Our Notice of Privacy Practices provides information about how we may use and disclose protected Health Information about you. By signing below, you acknowledge receipt of this notice. You have the right to review our notice before signing this acknowledgement. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting our Privacy Officer.

You have the right to request that we restrict how protected Health Information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.

CONFIDENTIALITY means that without your consent, Assistance and Recovery Program, Inc., shall neither confirm or deny that you are a client here. Your right to confidentiality is protected by Federal Law (42 CFR, Part 2) and State Law (W.I. CODE, Section 532B). There are legal exceptions to confidentiality in which information is required to be release, even without client consent.

  1. When testimony or release of records is ordered by the court.
  2. When there is good cause to suspect neglect or abuse of any minor child or elderly/dependent adult. Suspected abuse must be reported to the authorities for investigation.
  3. When required for adequate medical care.
  4. When a client is believed to be a danger to self or unable to care for self as the result of a mental disorder.
  5. When there is good cause to believe that a client will seriously harm another, it is required that the intended victim be warned and the law enforcement is notified.

If you have any questions or concerns about limits of confidentiality, please discuss this issue with your counselor.

Federal and state laws specify penalties for unauthorized release of information by service providers.

Unauthorized release of information can result in civil suit being brought by the injured party.

No client information shall be released, other than by order of the court, if there is cause to believe that such release of information may harm a person’s best interest as a client.

Federal law and regulations do not protect any information about a crime committed by a client, either at the program or against any person who works for the program or about any threat to commit such a crime.

I, the undersigned, acknowledge that I have received a copy of the form and have read, understood, or have had the above summary information on confidentiality explained to me as attested to by my signature below.