Client Intake Sheet


 Appointment Date: _­­­­­­­­­­­­­­­­­____________ Client #:­_____________

Date :  

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

Pronoun:
Sex: 

Gender

Options Location:


Primary Language:       Interpreter Needed?


Primary - Physical Address :
                                               
                                               

Primary - Mailing Address:
                                             
                                               
                                             
Okay to send mail from Options?

Alternate - Physical Address :  
                                                   
                                                    

Alternate - Mailing Address:
                                                 
                                                 
                                                  
Okay to send mail from Options?


Primary Phone #:
Name:  Relationship to Client:   
Type of Phone OK to ID : Ok to text : Appt. Reminder to this #  

Secondary Phone #: 
Name:  Relationship to Client: 
Type of phone Ok to ID Ok to text  

Guardian 1 Phone: (if applicable):
Name:  Relationship to Client:   
Address:
                   
                    
Okay to send mail from Options?
Type of phone Ok to ID Ok to Text  

Guardian 2 Phone: (if applicable):  
Name:
Relationship to Client:
Address: 
                     
                      
Okay to send mail from Options?
Type of phone Ok to ID Ok to Text  

Emergency Contact Phone #: 
Name: Relationship to Client:  
Type of phone Ok to ID Ok to Text  

 


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 :  

Contact Name : Phone :  
Agency/Program :   Fax :  


Payment Arrangements:
Insurance policy number/OHP ID :   Group # :  
Policy Holder Name:    Phone :

I have made other payment arrangements

 


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):

Ethnicity (Please check from the following):


Marital Status (Please check from the following):

Are you a Veteran?:



Tobacco Use (in the last 90 days):
Substance Use (in the last 90 days):
(alcohol or non-prescribed medications)


Employment Status of the Client (Please check from the following):
Highest Grade Completed :   Are you currently enrolled in school/training?:  
School Name: Current Grade :  


Living Arrangements (Please check from the following):           


Estimated Monthly Household Income: $


Primary Source of Income (Please check from the following):


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):


Are you currently pregnant?:


Referred From – How did you hear about Options? Personal Support System: Health Care Providers: Justice System: Other :


Comments / Questions :

Leave this empty:

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Signature Certificate
Document name: Client Intake Sheet
lock iconUnique Document ID: afd0fb7219eaf10cad871d63c710271d19466170
Timestamp Audit
November 25, 2020 7:46 am PDTClient Intake Sheet Uploaded by Adam Falk - adam.falk@options.org IP 108.174.191.149
November 25, 2020 11:03 am PDTOptions Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 108.174.191.149
November 25, 2020 11:05 am PDTOptions Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 108.174.191.149
December 1, 2020 8:33 am PDTOptions Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 108.174.191.149
December 2, 2020 2:17 pm PDTOptions Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.238.71.126
December 15, 2020 8:08 am PDTOptions Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 108.174.191.149
January 22, 2021 9:26 am PDTOptions Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 108.174.191.149
January 22, 2021 9:43 am PDTOptions Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 108.174.191.149
March 15, 2021 11:07 am PDTOptions Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 108.174.191.149
March 15, 2021 11:09 am PDTOptions Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 108.174.191.149