"*" indicates required fields CompanyThis field is for validation purposes and should be left unchanged.ENROLLMENT 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 clinical need and provide you with behavioral health services. MRWH provides services and benefits to its clients without regard to race, color, religion, gender, sexual orientation, national origin, age, handicap, or economic status. Reason(s) for Seeking Services: Medication Management Mental Health Therapy Substance Abuse Treatment Other Referral By:Other Reason for Seeking ServicesPLEASE COMPLETE THIS SECTION SPECIFIC TO THE INDIVIDUAL ENROLLING INName* 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 Preferred contact Text Phone/Voicemail Email Cell#*Home #Work #Social Security #Email Appointment Details & RemindersOkay to leave a voice message?* Yes No Okay to text/email reminder?* Yes No Do you want to receive automated text reminders?* Yes No 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 #This field is hidden when viewing the formLegal Status: Voluntary Court Order Civil Involuntary Criminal Involuntary Unknown CONTACT INFORMATION: IN CASE OF AN EMERGENCY In case of an emergency and/or scheduling changes, I give consent for MRWH to contact: Name First Middle Last Relationship:Address Street Address City State / Province / Region ZIP / Postal Code Home #:Work #:Call #:DEMOGRAPHIC INFORMATION Race/Ethnicity: Caucasian Asian American Indian, Alaskan Native African American Native Hawaiian, Other Pacific Hispanic/Latino Unknown More than one race Marital Status: Married Divorced Widowed Separated Single, Never Married Employment Status: Full-time Part-time Retired Disabled Student Homemaker Supported/Sheltered Employment Unemployed, but desiring work No interest in work Other Education Status: No formal education Adult Education (GED) Vocational School College part-time College full-time Home School Public School K-12 Private School Other Last grade completed:Homeless: Couch Surfing/Hotel Mission/Shelter Street/Transient Living Arrangements: Independently Alone Independently with Others Living with Others (in their care) Supported Independent Living Mental Health Group Home Non-MH Group Home Personal Care Home Nursing Home Jail/Pre-Release Hospitalization (Medical) Hospitalization (Psychiatric) Foster Care Therapeutic Foster Care Other Legal Custody: Self Parent/Grandparent Guardian Dept of Family Services Other Family Dept of Corrections/Juvenile Justice Indian Affairs/Tribal Court Other Military Experience Yes No Not Applicable Please provide branch: Airforce or Airforce Reserve Air National Guard Army or Army Reserve Army National Guard Coast Guard or Coast Guard Reserve Marine Corp or Marine Corp Reserve Navy and Navy Reserve Space Force Other, please specify:INSURANCE INFORMATIONPlease complete all that apply. Include policy/ID#. Identify as Primary or Secondary by circling. MEDICARE Policy IDtype Primary Secondary MEDICAID Policy IDtype Primary Secondary TRICARE Policy IDtype Primary Secondary VA: Is care for Sponsor Dependent Sponsor SSNtype Primary Secondary or DOD Benefit #(11-digits NOT the DOD Military card ID #)Commercial Insurance Commercial Plan NamePolicy IDGroupSELF PAY SELF PAY Needing Financial Assistance/Sliding Fee CAPTCHAPlease bring the appropriate insurance card(s) with you to your initial appointment Thank you!
