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Annual Update Sheet

Appointment Date: _____________ Client #:_____________

Date :

Client Legal Name:
Chosen Name: Date of Birth:
Birth/Maiden Name: Social Security #:

Pronoun: He/Him She/Her They/Them Other

Sex at the time of Health Plan enrollment Male Female Other

Gender Male Female Genderqueer (neither male or female)

Options Location:

Primary Language: Interpreter Needed? Langue ASL

Primary - Physical Address :

Primary - Mailing Address: Same as physical

Okay to send mail from Options? Yes No

Alternate - Physical Address :

Alternate - Mailing Address: Same as physical

Okay to send mail from Options? Yes No

Primary Phone #:
Name: Relationship to Client:
Type of Phone Home Cell Work

OK to ID : Yes No

Ok to text : Yes No

Appt. Reminder to this # Calls Text

Secondary Phone #:
Name: Relationship to Client:
Type of phone Home Cell Work

Ok to ID Yes No

Ok to text Yes No

Guardian 1 Phone: (if applicable):
Name: Relationship to Client:
Address:

Okay to send mail from Options? Yes No

Type of phone Cell Home Work

Ok to ID Yes No

Ok to Text Yes No

Guardian 2 Phone: (if applicable):
Name: Relationship to Client:
Address:

Okay to send mail from Options? Yes No

Type of phone Cell Home Work

Ok to ID Yes No

Ok to Text Yes No

Emergency Contact Phone #:
Name: Relationship to Client:
Type of phone Home Cell Work

Ok to ID Yes No

Ok to Text Yes No

Client Support System:

Spouse \ Partner : Phone :

Other Household Members (Siblings, Roommates):
Name/Relationship to Client : Age:
Name/Relationship to Client : Age:
Name/Relationship to Client : Age:
Name/Relationship to Client : Age:

Primary Care Doctor: Phone :
Clinic Name : Fax :
Dental Provider : Phone :

Other Agencies, Case Workers, or Health Care Providers Involved:

Contact Name : Phone :
Agency/Program : Fax :

Client Demographic Data:

It is the policy of Options Counseling and Family Services to be non-discriminatory in the delivery of services to clients without regard to race, color, religion, national origin, age, gender, disability, source of income, gender identity or expression, and/or sexual orientationOptions is required to request the following information for Oregon Department of Human Services for the Measures and Outcomes Tracking System (MOTS). This data is collected and used to determine funding levels and effectiveness of mental health programs in our community.

Marital Status (Please check from the following):
Never Married Married Widowed Divorced Separated I prefer not to respond

Are you a Veteran?:
Yes, Current/Former Active Duty Military Yes, Current/Former Guard/Reserve No, But Current/Former Guard/Reserve Military No

Tobacco Use (in the last 90 days): Yes No I Prefer Not to Share

Substance Use (in the last 90 days):
(alcohol or non-prescribed medications) Yes No I Prefer Not to Share

Employment Status of the Client (Please check from the following): I Prefer Not to Share Full Time (over 35 hours/week) Student Sheltered/Non-Competitive Employment Part Time (under 35 hours/week) Retired Not in the Labor Force Unemployed – Seeking Employment Disabled Other Classification (ex. Volunteers) Homemaker Hospital or Institutional Resident

Highest Grade Completed : Are you currently enrolled in school/training?: Yes No

School Name: Current Grade :

Living Arrangements (Please check from the following):
Private Residence Residential Facility (BRS) Supported Housing – Scattered Site Private Residence (at home) Residential Facility (CSEC) Supported Housing – Congregate Setting Private Residence (with relative) Residential Facility (PRTS) Private Residence (with non-relative) Residential Facility (SCIP/SAIP) Residential Facility (SRTF -YAT) Oxford Home Transient/Homeless Secure Residential (SRTF Adult) Alcohol/Drug Free Housing Foster Home Residential SubAcute Facility Supported Housing – Other Type Jail Room & Board-Independent Living Facility Residential Facility/Group Home Residential Facility (SUD) Prison Other

Estimated Monthly Household Income: $

Prefer Not to Share

Primary Source of Income (Please check from the following):
I Prefer Not to Share Wages/Salary Retirement/Pension SSI Other Public Assistance Disability/SSDI None

Dependents (Include the total number of persons, including the client, that are supported by the household income) :
Adults (include minors living independently) : #
Children (include minors for which child support is paid out of this income): #

Are you currently pregnant?: Yes No Not Applicable/Male I Prefer Not to Share

Comments / Questions :

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Your email address

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Timestamp

Audit

January 22, 2021 9:51 am PST

Annual Update Sheet Uploaded by Adam Falk - adam.falk@options.org IP 69.1.101.108

January 22, 2021 10:42 am PST

Options Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 108.174.191.149

September 13, 2021 1:03 pm PST

Options Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48

September 29, 2021 1:23 pm PST

Options Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48