Client Intake


 



Client Information:


Client Name  Last:  First: ­  Middle:

Preferred Name: Birth/Maiden Name:

Gender:


Other : 

Identify as:


Other : 

Preferred Pronoun:

 Other  

Date of Birth:   Social Security:  

Options Location:


Primary Language: Interpreter Needed?  

 


Primary Phone Number:  
Type of Phone  :

Okay to receive appt. reminder texts:     
Okay to use Options’ name:  
Best times to call:  

Alt. Phone Number:
Type of Phone:     
Okay to receive appt. reminder texts:   
Okay to use Options’ name:  
Best times to call:  

Available for an appointment on Saturday:

Are you a previous Options Client:
Are you a current client at any other agency:
Has the court recommended treatment:
 


Physical Address : 

Mailing Address  :  

Okay to send mail from Options: 

 


If client is a child, please answer the following:

Guardian Name: Relationship:  
Address: Phone Number:  
Guardian Name: Relationship:
Address: Phone Number:  

Siblings:
Name : Age : Name : Age :  
Name : Age : Name : Age :  
Teacher :   School :   Grade :  


Emergency Contact:
Name :   Phone Number :  
Okay to ID Options :

Okay to use as an alternate contact:
 


DHS Caseworker (if applicable):
Name :   Phone Number :  
Email :   Fax Number :  


Payment Arrangements :

OHP Number :   Effective Date :  

Private Insurance – please provide information on any private insurance coverage within the last 12 months:
Company :   Policy Holder :  
Policy/ID Number :   Group Number :  
Phone Number :   Fax Number :  


I have made other payment arrangements**

 (**All payment arrangements are subject to Options Billing Department verification and approval)


Client Support System :


Spouse/Partner:   Phone:  
Primary Care Doctor :   Phone :  
Clinic Name :   Fax :  
Dental Provider :   Phone :  
Clinic Name :   Fax :  

Other Agencies, Caseworkers, or Health Care Providers Involved:

Contact Name :   Phone :  
Agemcu / Program :   Fax :  
Contact Name :   Phone :  
Agency / Program :   Fax :  

*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 orientation.* 

Options 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.

Client Demographic Data:

Race (Please check from the following):


Ethnicity (Please check from the following) :
Other Specific Hispanic  


Marital Status (Please check from the following):


Are you a Veteran?

 


Tobacco Use (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?:

 


Living Arrangements (Please check from the following):
Other :  


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): #  


Referred From – How did you hear about Options?
Local or State Agencies:


Personal Support System:
 
Health Care Providers:

Justice System:

Other


Tribal Affiliation (Please check from the following):


Are you currently pregnant?

Leave this empty:

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Options Counseling & Family Services https://wp.options.org
Signature Certificate
Document name: Client Intake
lock iconUnique Document ID: 14c7de2bc9733154d87c657aeb8baba1cfcac5ba
Timestamp Audit
April 29, 2020 8:14 am PDTClient Intake Uploaded by Adam Falk - adam.falk@options.org IP 50.240.25.195
April 30, 2020 11:16 am PDTOptions Records - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
May 4, 2020 7:52 am PDTOptions Records - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
May 12, 2020 7:41 am PDTOptions Records - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195