Reach For Tomorrow Mental Health Screen

Mental Health Screen

Thank you for choosing REACH for Tomorrow. This confidential screening will help our Intake Team better understand your needs and determine the appropriate next steps for services. What to Expect: Takes approximately 5–7 minutes to complete Your information is securely transmitted. An Intake Coordinator will contact you within 48 business hours. Important: Completing this screening does not guarantee admission into the program. Admission is based on eligibility, clinical appropriateness, program availability, and completion of the intake review process.
Today's date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Full Name

First NameLast Name
Client Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Email Address
example@example.com
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What type of insurance coverage do you currently have?
Which Medicaid plan do you have?

Other
What is the name of your insurance company?
Would you like information about possible payment or insurance options?
Is the insurance policy under a different person’s name?
Member ID #
Policyholder name, if different from client

First NameLast Name
Client age group?
Guardian Full Name

First NameLast Name
Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian relationship to client

Other
What type of support or services are you interested in?

Other
PLEASE STOP!

If you are seeking Intensive Outpatient (IOP) services with Supportive Housing, an additional IOP Screening Application is required.

Please do not continue with this form. Complete the IOP Screening Application instead so our Intake Team can properly review your request for admission.

If you are unsure which screening to complete or need assistance, please contact the REACH for Tomorrow Intake Team at (740) 273-8040.
What location are you needing?
Which of the following are you currently experiencing?

Other
Immediate Safety Information
If you are experiencing a mental health crisis, call or text 988 to reach the Suicide & Crisis Lifeline. If you are in immediate danger or believe you may act on thoughts of suicide or self-harm, call 911 or go to the nearest emergency department.

This form is not monitored continuously and should not be used for emergency assistance
Please briefly tell us what is happening and what you would like help with.
Are you currently having thoughts of hurting yourself?
Immediate Safety Information
If you are experiencing a mental health crisis, call or text 988 to reach the Suicide & Crisis Lifeline. If you are in immediate danger or believe you may act on thoughts of suicide or self-harm, call 911 or go to the nearest emergency department.

This form is not monitored continuously and should not be used for emergency assistance.
Are you currently having thoughts of hurting someone else?
If you believe you may act on thoughts of harming another person or someone is in immediate danger, call 911 or go to the nearest emergency department.

This form is not monitored continuously and should not be used for emergency assistance.
Do you currently take medications? (OTC or prescriptions)
Please list the name and dosage of your current medication(s), if known.
How did you hear about Reach for Tomorrow?

Other
Where did you hear about us online?

Other
When are you generally available?
What day of the week are you available
Please Note: Individual sessions may be scheduled on weekends based on the clinical schedule and clinician availability.
Can we leave a voicemail?
Can we text you?
If yes, What is a good text number if different ?
Is there anything else you would like us to know?
Should be Empty: