"*" indicates required fields INITIAL CONTACT FORM This form is a part of your MRWH record, and the information provided will be treated as confidential. This information is required in order for us to identify your need and provide you with services. MRWH provides services and benefits to its clients without regard to race, color, religion, gender, national origin, age, handicap, or economic status. FAX Forms/Medical Records TO ATTN: CARE COORDINATOR 406-761-2107: CURRENTLY EXPERIENCING ANY OF THE FOLLOWING? Please check all that apply Please check all that apply IN LAST 30 DAYS attempted suicide IN THE LAST 30 DAYS thought about harming yourself or others Actively using Alcohol and/or Drugs and are seeking treatment Experiencing withdrawal symptoms Please select if you are a referring provider PROVIDER REFERRAL Please send last chart note and current patient demographic sheet with recordsReason for seeking services/Provider referral*PLEASE COMPLETE THIS APPLICATION SPECIFIC TO THE PERSON SEEKING SERVICESName* First Middle Last Date of Birth* Month Day Year Age* Gender* Male Female Transgender Other AddressAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home #Work #Cell#*Other/Message Phone #Email Address Social Security # Complete only if applicant is under the age of 18 OR if the client has a legal guardianParent/Guardian Name: if applicant is under the age of 18 OR if the client has a legal guardianHome #Address, if different from above: if applicant is under the age of 18 OR if the client has a legal guardianCell#*Relationship/Agency: if applicant is under the age of 18 OR if the client has a legal guardianWork #Legal Custody: Self Parent/Grandparent Guardian Dept of Family Services Dept of Corrections/Juvenile Justice Bureau of Indian Affairs/Tribal Court Other Family INSURANCE INFORMATIONDo you have MEDICARE? Yes No Policy ID#Do you have MEDICAID? Yes No Policy ID#VA: Is care for Sponsor Dependent Sponsor SSN or DOD Benefit #(11-digits NOT the DOD Military card ID #)Private InsurancePlan Name Policy ID#Group#Do you have TRICARE? Yes No Policy ID#SELF PAY SELF PAY I consent to services being provided via telehealth and/or phone as allowable and appropriate to the service(s) I am receiving.* Yes No Initials* I agree to be contacted by MRWH via the phone number(s) and/or email address listed on this form.* Yes No Initials* Client Signature* Client Printed Name* Relationship/Agency* Date MM slash DD slash YYYY Referring Agency Referring Provider Contact Name Phone NumberDate MM slash DD slash YYYY MIDAS (Mental Illness, Drug and Alcohol Screening) Please answer as related to the last 6 months only.1. Do you feel that you have a problem with your use of drugs and/or alcohol and/or gambling?* Yes No 2. Do you use drugs, alcohol, or gambling even though your doctor or other providers recommend that you do not?* Yes No 3. Is your family concerned about your drugs and/or alcohol or gambling?* Yes No 4. Are your providers concerned about your drugs and/or alcohol or gambling?* Yes No 5. Have you had legal problems or engaged in illegal activity (other than using drugs) due to drugs and/or alcohol or gambling?* Yes No 6. Have you had medical problems related to, or worsened by, drugs and/or alcohol or gambling?* Yes No 7. Do you use drugs and alcohol or gambling to relieve mental health symptoms?* Yes No 8. Do you find that using drugs and/or alcohol or gambling worsens your mental health symptoms?* Yes No 9. Do you have problems taking your psychiatric medication as prescribed because of drugs and/or alcohol use or gambling?* Yes No 10. Have you gotten in trouble, including getting in trouble at a mental health treatment program, because of drugs and/or alcohol or gambling?* Yes No 11. Have you had ER visits or psychiatrics hospitalizations that were connected to drugs and/or alcohol use or gambling?* Yes No 12. Do you every feel guilty about your drugs and/or alcohol use or gambling?* Yes No 13. Have you experienced withdrawal symptoms or intense cravings to use drugs or alcohol or to gamble?* Yes No 14. Have you attend self-help (e.g., 12 Step) meetings relating to drugs and/or alcohol use or gambling?* Yes No 15. Have you received any addiction treatment, including detoxification?* Yes No 16. Have you felt unable to control your use of any drug or alcohol or gambling?* Yes No 17. Do you consider yourself to be an alcoholic or drug addict or gambling addict?* Yes No 18. Do you engage in the use of alcohol, drugs, or gambling activity three times a week or more?* Yes No *Adapted with expressed permission for use from Dr. Ken Minkoff, MD developer of the MIDAS Screening Tool. *Client self-reported form is located in electronic Clinical Record with Application documents. *See Intake Assessment under Substance Abuse section for full clinical assessment.CommentsThis field is for validation purposes and should be left unchanged.
