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Initial Telephone Contact

If you are human, leave this field blank.

Full Name: *

Date *

Time *

Address *

Apt, suite, etc.

Country

City

State

Zip code

*

Foster Care/Group Home/ Nursing Home

Legal Guardian *

Agency/Person Who Provides Background Information: *

SS# *

Telephone *

Bus. Phone *

Sex *

Adult/Child *

Date of Birth *

Age *

Annual Gross Income *

Monthly Gross Income *

Race *

Ethnicity *

Family Size *

Pregnant *

Marital Status *

Spouse Name *

Number of Children *

Notes *

Payment Arrangements *

If Other *

Insurance Name *

Policy# *

Claim\'s Address *

Apt, suite, etc.

Country

City

State

Zip code

Subscriber\'s Name *

SS# *

Employer *

Group# *

Insurance Phone# *

Other Payment Source *

Deductible/Co-Pay *

Amount Due 1st Session *

Notes *

Involvement *

If court which one *

If CPS what county *

Court Ordered *

Which Court *

Court Address *

Apt, suite, etc.

Country

City

State

Zip code

Probation/Parole Officer *

Notes *

*

Counseling

*

Group

*

Assesment

(see assessment intake form)

*

CSP

*

Medication/Somatic

Notes *

Have or are you receiving mental health services from another agency in the past 12 months? *

Yes

No

If so where? What type of services? *

Do we have permission to access your Medicaid Client Eligibility and Benefits Information? *

Yes

No

Program *

Reason for Seeking Services *

Factors effecting client assignment *

Scheduling Conflicts/Restraints *

Urgency *

Appointment Offered *

Time *

Therapist *

Appointment Scheduled *

Time *

Therapist *

Who referred you/told you to come for services? *

Specify name of referral source *

How did you hear about us? *

If Other *

Person Taking Intake *

Client Information was *

Mid-Ohio Psychological Services, Inc. provides high-quality, cost-effective, culturally-sensitive, socially-responsible, mental health, substance abuse, and support services to individuals and community organizations, while offering professional development to its staff and other professionals in the field.

To achieve our mission, we value...
Personal Growth * Integrity * Inclusion * Strong Relationships * Adaptability * Results