NEW OP Pre-Intake Form
Language
  • English (US)
  • Español

  • Caregiver Pre-Intake Form

  • We ask every family to complete the Central Intake Form prior to scheduling an intake appointment. Please complete this form to the best of your ability and one of our intake specialists will contact you when we have appointments available to schedule. This form can be completed by the legal guardian/parent, caregiver, or the child/youth (if 14 years or older).

    Please Note:

    · This form is for Outpatient Mental Health (MH) Services.

    · Higher levels of Mental Health Services (including our Community-Based Services) require a referral from a current MH provider and/or Prior Authorization. If you are seeking these services and have not been referred and/or do NOT have a prior authorization, please contact the child/youth’s insurance provider for requirements to access these services.

    · Psychiatric Services and Substance Use Disorder Services are ONLY available to clients receiving MH services with Morrison.

    · We do NOT provide psychological evaluations/services, educational assessments, or developmental disability evaluations/services.

  • Has the youth received services with Morrison previously?
  • Is another youth/sibling in the home currently receiving services with Morrison?

  • Demographic Information

  • Date of Birth*
     - -
  • Sex Assigned at Birth*
  • Does the youth have a secondary address?

  • Language and Interpreter Services:

  • Are Interpreter Services Needed?*
  • Is English the child/youth’s primary language and the primary language spoken in the child/youth’s home?*

  • Race and Ethnicity

    Information about the race and ethnicity of our clients helps us provide quality services and access funding to support programs that meet the diverse needs of the families in our community. Providing this information is voluntary and will not impact the child/youth’s access to services.
  • Which of the following describes the child/youth’s racial or ethnic identity? Please check ALL that apply*
  • American Indian or Alaska Native
  • Asian
  • Black or African American
  • Hispanic or Latino/a/x
  • White
  • Native Hawaiian or Pacific Islander

  • Insurance Information

    Please provide the child/youth's insurance information. We accept the following insurance providers.
  • Please Note: we are NOT in-network with other insurance providers. We may not be able to provide services to the child/youth if their insurance is not listed below.*

  • Guardianship and Contacts

  • Is the child/youth currently in CPS/DHS or OYA custody?*
  • Has the child/youth ever had any Child Protective Services (CPS)/DHS or Oregon Youth Authority (OYA) involvement?*

  • DHS Caseworker/ Legal Guardian

  • Format: (000) 000-0000.

  • Legal Guardian 1:

  • Format: (000) 000-0000.

  • Legal Guardian 2: (if applicable)

  • Format: (000) 000-0000.

  • Primary Caregiver: (if different than Legal Guardian) 

  • Format: (000) 000-0000.

  • Child/youth: (if applicable)

  • Format: (000) 000-0000.

  • Primary Care Provider (PCP):

  • Format: (000) 000-0000.

  • Primary Contact for Scheduling: 

  • Who should we contact to schedule when we have appointments available?*

  • If Other, Provide Contact Information:

  • Format: (000) 000-0000.

  • Please note: A signed Release of Information (ROI) will need to be obtained from the child/youth's legal guardian or child/youth (if 14 years or older) for any other individuals involved in services except for other current providers.

  • Is the youth adopted?*
  • Does the child/youth have separated or divorced parents/caregivers?*
  • If yes, what is the current custody circumstances? (select all that apply)

  • Service Request Information

  • Morrison Location Requested: (If you select more than one location, please list your top preference)*

  • Reason for Requesting Services:

  • Does the child/youth have a diagnosed developmental disability, or do you have any developmental concerns?    (select all that apply)*
  • Is the youth Deaf or Blind?
  • Does the youth have any other physical disabilities?
  • Do you have any immediate safety concerns? (i.e. risk of harming self, risk of harming others, other safety/risk concerns, etc.)*

  • Treatment History:

  • Has the child/youth ever received mental health or substance use disorder services?*
  • Has the child/youth ever had a psychological or neuropsychological evaluation?*
  • Has the child/youth ever been prescribed psychiatric medication?*
  • For current psychiatric medications, will the prescriber continue to provide medication management or are you interested in receiving psychiatric services with Morrison?
  • Has the child/youth ever been psychiatrically hospitalized?*
  • Has the child/youth ever received any other type of treatment services? (i.e. Intellectual and Developmental Disability Services, ABA Services, Occupational or Speech Therapy, etc.)*
  • This form is meant for Legal Guardians/Caregivers or youths seeking services, is this form being completed with a Legal Guardian, Caregiver, or youth?*

  • Preferences for Services

    We will make every effort to accommodate your preferences but cannot guarantee any or all preferences will be recommended, clinically appropriate, or accommodated.
  • Services: (select all that apply)

  • Please Note: Parent-Child Interactive Therapy, Psychiatric Services/Medication Management, Respite Services, Skills Training, and Substance Use Disorder Services are not available at all locations and/or require clinical recommendation/referral from your assigned therapist.

  • Appointment Type:
  • Should be Empty: