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Client Intake Sheet

Appointment Date: _____________ Client #:_____________

Date :

Client Legal Name:
Client Date of Birth:
Chosen Name:

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

Email Address:
Okay to send email 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 :

Payment Arrangements:
Primary Insurance Ins Phone #
ID : Group # :
Policy Holder Name: DOB : Phone :

Secondary Insurance Phone :
ID : Group # : Ins Phone #
Policy Holder Name: DOB :

I have made other payment arrangements

Self Pay

Sliding Scale

Other

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.

Race (Please check from the following):
White Alaskan Native Other Single Race American Indian Asian Two or More Unspecified Races Black / African American Native Hawaiian / other Pacific Islander

Ethnicity (Please check from the following):
Not of Hispanic Origin Hispanic – No Specific Origin Other Specific Hispanic Puerto Rican Cuban Mexican Unknown

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): #

Tribal Affiliation (Please check from the following):
Not Applicable Confederated Tribes of Siletz Cow Creek Band of Umpqua Indians Burns Paiute Tribe Confederated Tribes of the Umatilla Klamath Tribes Confederated Tribes of Coos, Lower Umpqua & Siuslaw Confederated Tribes of Warm Springs Confederated Tribes of Grand Ronde Coquille Indian Tribe Other

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

Referred From – How did you hear about Options? Child Welfare Vocational Rehabilitation Aging and People with Disabilities Local Mental Health Authority Developmental Disability Services Community Mental Health Program School / Community Housing Employment Services

Personal Support System: Self Family / Friend Employee Assistance Program Advocacy Group Attorney

Health Care Providers: Community Substance Abuse Provider Community Mental Health Provider Coordinated Care Organization State Psychiatric Facility Private Health Professional (ex PCP, PHD, Hospital, Health Home)

Justice System: Federal Court Circuit Court Justice Court Jail Municipal Court Parole – including Juveniles Police or Sheriff Psychiatric Review Board Probation - including Juveniles State Correctional Institution Federal Correctional Institution Integrated Treatment Court Juvenile Justice System/OYA

Other : Crisis/Helpline Internet/Media Other None I Prefer Not to Respond

Comments / Questions :

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Timestamp

Audit

November 25, 2020 7:46 am PST

Client Intake Sheet Uploaded by Adam Falk - adam.falk@options.org IP 69.1.101.108

November 25, 2020 11:03 am PST