SPS- Healing Minds
EMPOWERING YOUTH
3170 W. Central Ave. Toledo, Ohio 43606
Phone: (567) 316-7253 Fax: (567) 316-7232
NEW CLIENT INTAKE INFORMATION
Client Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Male/Female:
Race:
School Name:
Grade:
Email:
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number:
Allergies (food, insects, medications, etc.)
Allergy Reaction:
GUARANTOR INFORMATION
Parent/Guardian Name:
First Name
Last Name
Relationship:
Primary Phone:
Format: (000) 000-0000.
Secondary Phone:
Format: (000) 000-0000.
Emergency Contact:
First Name
Last Name
Relationship:
Phone:
Format: (000) 000-0000.
Parent/Guardian Employer:
Phone:
Format: (000) 000-0000.
INSURANCE INFORMATION
Primary Insurance:
Policy Number:
If Medicaid, MMIS #:
Primary Policy Holder Name:
First Name
Last Name
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Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referred by:
Client Info
Name
First Name
Last Name
Phone
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN#:
Emergency Contact Name:
First Name
Last Name
Relationship to self:
Phone (Emergency Contact)
Format: (000) 000-0000.
Insurance Provider and Number:
Questionare
1. Gender
Male
Female
2. Race
3. Marital Status
4. Nicotine Use:
Yes
No
5. Language Spoken
6. Need Interpreter?
Yes
No
7. Are you currently employed?
Yes
No
8. Are you currently homeless?
Yes
No
9. Highest level of Education completed
10. Annual Household Income
Source of Income
Disability
Family
Public Assistance
Retirement/Pension
Wages Salary
None
Other
Unknown
11. How many living in a household?
12. How many individuals under 18 in your household?
13. Number of independents?
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14. Do you currently have Ohio Medicaid health insurance?
Yes
No
15. Do you have a legal guardian or payee?
Yes
No
16. Do you have a drug or alcohol addiction?
Yes
No
17. Do you need detox services?
Yes
No
18. When was the last time you used drugs/alcohol?
Drug of choice:
19. Have you at any point of time received services with Empowered for Excellence?
Yes
No
20. Are you currently receiving Mental Health or Substance Use services elsewhere?
No
If yes, where:
21. Please specify all medications and supplements you are presently taking and for what reason:
22. If taking prescribed medication, who is your prescribing Doctor? Please include doctor specialty, name, phone number:
23. Please check all that apply to your current physical health problems:
Hormone-related problems
Headache
Irritable Bowel
Chronic Fatigue
Head injury
Chronic Pain
Heart Attack
Gastritis or Esophagitis
Seizures
Cancer
Angina or chest pain
Bone or Joint problems
Asthma
Dizziness
Kidney-Related
Numbness and Tingling
Faintness
Hepatitis
Fibromyalgia
Heart valve problems
Diabetes
Thyroid issues
Shortness of breath
Urinary tract problems
Arthritis
HIV/AIDS
Loss of consciousness
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24. Is there any other information you would like us to know?
Client/Parent/Guardian Signature
Relationship to client
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Client Orientation Checklist
Client Name:
First Name
Last Name
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please have client initial once presented to, explained and/or completed by client:
Mission/Introduction
Code of Ethics
Anti-Harassment Notice
Services/Hours of Operation
Consent for Treatment
Consent for Contact
Consent for Telehealth
Access to Services After Hours
Treatment Process
Urine Collection (As Applicable)
Clients Rights MH or SUD
Confidentiality Laws
HIPPA/Privacy Rights
Grievance Procedure
Client Rules and Expectations
Site Safety / Facility tour
Termination of Services
Hep B & C, TB, HIV/AIDS
Privacy Practices
Consent for Emergency Contact
Submit
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