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OHM Mental Health Wellness Center
How may we help you?
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New client seeking treatment
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Refer a client/patient
Integrated care consult
Ask a general question
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What type of treatment?
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Medication Management
Substance Use Treatment
Therapy Appointment
Psychological Testing
TMS Therapy
Spravato® (Esketamine) Treatment
General for Depression/Anxiety
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Who is the treatment for?
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Myself
My child
Other family member or friend
My client/patient
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What type of appointment?
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Medication Management
Substance Use Treatment
Therapy Appointment
Psychological Testing
TMS Therapy
Spravato® (Esketamine) Treatment
General for Depression/Anxiety
Other
Who is the appointment for?
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Myself
My child
Other family member or friend
My client/patient
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Organization type
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Healthcare organization
Group practice
Individual practice
School
Community organization
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Organization name
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Reason for contact
Referral
Coordinated care
On-site visit and consultations
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Referred by
First Name
Last Name
Your name
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First Name
Last Name
Your child's name
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First Name
Last Name
Your friend/family member's name
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First Name
Last Name
Your client/patient's name
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First Name
Last Name
Your email
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example@example.com
Your phone number
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Area Code
Phone Number
Best time to be reached?
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Insurance provider
Policy number
Member name
First Name
Last Name
Member date of birth
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Month
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Day
Year
Date
Preferred location(s)
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Lewiston
Telehealth
Clinician name
First Name
Last Name
Credentials
CADC
LCSW
LMFT
LMHC
Psy.D.
Ph.D.
ARNP
MD
Other
Clinician email
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example@example.com
Name of organization
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Type of service for referral
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Telehealth
Adult counseling
Addiction treatment (IOP)
Addiction treatment (EOP)
Depression and/or anxiety treatment
Couples counseling
Family counseling
Older adult services
Child & adolescent services
Youth IOP services
Youth EOP services
Psychological assessment
Medication manangement
TMS therapy
Esktamine nasal spray
Other
How did you hear about us?
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Attorney
Clinical professional
Community event
County
Current or previous client
Family or friend
Flyer
Hospital, urgent care, or medical facility
Insurance site or listing
Internet search
Law enforcement
School or college
Social media
VA
Yelp
Other / don't recall
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