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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
Please select if you are a referring provider
Please send last chart note and current patient demographic sheet with records

PLEASE COMPLETE THIS APPLICATION SPECIFIC TO THE PERSON SEEKING SERVICES

Name*
Date of Birth*
Gender*
Address
Address*

Complete only if applicant is under the age of 18 OR if the client has a legal guardian

if applicant is under the age of 18 OR if the client has a legal guardian
if applicant is under the age of 18 OR if the client has a legal guardian
if applicant is under the age of 18 OR if the client has a legal guardian
Legal Custody:

INSURANCE INFORMATION

Do you have MEDICARE?
Do you have MEDICAID?
VA:
(11-digits NOT the DOD Military card ID #)
Private Insurance
Do you have TRICARE?
SELF PAY
I consent to services being provided via telehealth and/or phone as allowable and appropriate to the service(s) I am receiving.*
I agree to be contacted by MRWH via the phone number(s) and/or email address listed on this form.*
MM slash DD slash YYYY
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?*
2. Do you use drugs, alcohol, or gambling even though your doctor or other providers recommend that you do not?*
3. Is your family concerned about your drugs and/or alcohol or gambling?*
4. Are your providers concerned about your drugs and/or alcohol or gambling?*
5. Have you had legal problems or engaged in illegal activity (other than using drugs) due to drugs and/or alcohol or gambling?*
6. Have you had medical problems related to, or worsened by, drugs and/or alcohol or gambling?*
7. Do you use drugs and alcohol or gambling to relieve mental health symptoms?*
8. Do you find that using drugs and/or alcohol or gambling worsens your mental health symptoms?*
9. Do you have problems taking your psychiatric medication as prescribed because of drugs and/or alcohol use or gambling?*
10. Have you gotten in trouble, including getting in trouble at a mental health treatment program, because of drugs and/or alcohol or gambling?*
11. Have you had ER visits or psychiatrics hospitalizations that were connected to drugs and/or alcohol use or gambling?*
12. Do you every feel guilty about your drugs and/or alcohol use or gambling?*
13. Have you experienced withdrawal symptoms or intense cravings to use drugs or alcohol or to gamble?*
14. Have you attend self-help (e.g., 12 Step) meetings relating to drugs and/or alcohol use or gambling?*
15. Have you received any addiction treatment, including detoxification?*
16. Have you felt unable to control your use of any drug or alcohol or gambling?*
17. Do you consider yourself to be an alcoholic or drug addict or gambling addict?*
18. Do you engage in the use of alcohol, drugs, or gambling activity three times a week or more?*

*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.

This field is for validation purposes and should be left unchanged.

OUR MISSION

Many Rivers Whole Health partners with people and communities to serve the whole person body, mind, spirit by providing wellness expertise in mental health and substance abuse services.

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DISCLAIMERS

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SERVICES

Quality of Life Management
Mental Health Services
Relationship Coaching
Addiction Recovery

CONTACT

Great Falls Regional Office
915 1st Ave South
P.O. Box 3089
Great Falls, MT 59403
406.761.2100
1.888.718.2100

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