Website Intake Form

Name*

First NameLast Name

Maiden Name

Date of Birth*

Date

SSN*

What is your cell phone provider? (This allows us to send a text message reminder for upcoming appointments.)*

Email*

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County

Phone Number*

Please enter a valid phone number.Format: 000-000-0000.

Can we leave a voicemail & send a text message to this number?*

If yes, what can we say?

Hispanic/Latino

Preferred Pronouns

Sex

Substance Abuse Support For MyselfMental Health Support For MyselfGambling Support for MyselfI am a Family Member / Supportive Adult of Someone Else With Substance Abuse / Mental Health / Gambling ChallengesI Was Referred to The Virtue Center By Some Other Entity & I Am Required to Be Here.Other

Other / More Detail:

How did you hear about us? (Who told you to come here?)*

Do you have commercial insurance? **Please provide insurance card to reception***

If answered "Yes" to question above, what is the name of your commercial insurance provider?

Do you have Soonercare / Medicaid?*

Household Income*

Frequency (How often do you get paid this amount?)

How many people in your household are you financially responsible for? (Include yourself)*

List Any Special Needs or Accommodations:

Are you currently pregnant?

Do you use tobacco products?

If yes, would you like assistance with quitting nicotine use?

If yes, please sign below: "I authorize the Oklahoma Tobacco Helpline to contact me."

List Any Additional Information You'd Like Us to Be Aware:

Authorization for Release of Protected Health Information for Insurance Discovery

I understand that TVC may need to disclose certain Protected Health Information (PHI) in order to determine my insurance coverage, benefits, and eligibility for services. By signing below, I authorize TVC to share the minimum necessary information with insurance companies, payers, or third-party verification services for the purpose of insurance discovery, eligibility verification, and coordination
of benefits.
This information may include identifying information (such as my name, date of birth, and contact information), service information, and other relevant details necessary to determine insurance coverage.
I understand that this disclosure is permitted for the purpose of payment and health care operations and is conducted in accordance with applicable privacy laws, including HIPAA. I also understand that this authorization allows TVC to obtain information from insurance sources as needed to identify potential coverage for services.
By signing this Intake Form, I acknowledge that I have read and understand this authorization and voluntarily consent to the release of my information for the
purposes described above.

FINANCIAL AFFIDAVIT

ANNUAL INCOME DESCRIPTION: Enter the dollar amount only (no cents), which represents the total combined annual income of the customer and any individuals with which the customer is financially interdependent. If annual income is unknown, multiply the estimated monthly income by 12. As defined by the DMHSAS eligibility criteria, income includes total annual cash receipts before taxes from all sources, with the exceptions noted below: Income includes money, wages, and salaries before any deductions; net receipts from non-farm self-employment (receipts from a person’s own unincorporated business, professional enterprise, or partnership, after deductions for business expenses); net receipts from farm self employment (receipts from a farm which one operates as an owner, renter, or sharecropper, after deductions for farm operating expenses); regular payments from social security, railroad retirement, unemployment compensation, strike benefits from union funds, workers’ compensation, veterans’ payments, public assistance (including Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), and non-federally-funded General Assistance or General Relief money payments), and training stipends; alimony, child support, and military family allotments or other regular support from an absent family member or someone not living in the household; private pensions, government employee pensions (including military retirement pay), and regular insurance or annuity payments; college or university scholarships, grants, fellowships, and assistantships; and dividends, interest, net rental income, net royalties, periodic receipts from estates or trusts, and net gambling or lottery winnings. Income does not include non-cash benefits, such as the employer-paid or union-paid portion of health insurance or other employee fringe benefits, food or housing received in lieu of wages, the value of food and fuel produced and consumed on farms, the imputed value of rent from owner-occupied non-farm or farm housing, and such federal non-cash benefit programs as Medicare, Medicaid, food stamps, school lunches, loans, and housing assistance.

I certify that my income, or lack of income, has been reported in truth and entirety. I understand that if my income circumstances change int eh future, I am required to report the change. I also understand that knowingly making false claims regarding these statements is an offense punishable by law.

Signature