New Client Form

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First name

Last name

Birthday

Gender

Male

Female

Transgender

Address

Social Security Number

Phone

Email

Insurance/Carrier

Medical Assistance ID

Parent/Guardian

Phone

Reason for interest

Requested BH Services

Is the client in active mental health treatment?

Yes

No

Have the client in the past participated in any mental health treatment

Yes

No

Are you currently prescribed medication

Yes

No

If yes, list current medication

Name of referring provider, provider email , company address phone number and fax:

Please select what is needed

Check if any is your current place of residence.

Consumer Name

Consumer Signature

Legal Guardian, if a minor

Legal Guardian Signature, if a minor

Date

PLEASE NOTE

During the PHP program: The focus will be to make sure that you have the following:Birth Certificate, Social Security Card, Primary Care Physician, Dental, Vision, OBGYN appointments, if needed, and SNAP/TCA benefits, if needed.

During the IOP program: We will focus on assisting you with obtaining TDAP, SSI/SSDI, MDOT-MTA, and cellular phone.

During the OP/3.1 program: Approaching graduation from our program, we will assist you with obtaining the following: Housing, Resume Writing, Savings Account,School/Job Training.

New Client Form

Our Address

Contact Details

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