"*" 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. 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 Daily OR ANY combo use of Heroin, Fentanyl, Alcohol or Benzodiazepines Actively using Alcohol and/or drugs and are seeking treatment. Experiencing withdrawal symptoms Other Reason for seeking service/Referral by:*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 Preferred contact Text Phone/Voicemail Email Cell#*Home #Work #Social Security # Email Address Previous Provider Pharmacy Appointment Details & RemindersOkay to leave a voice message?* Yes No Okay to text/email reminder?* Yes No Preferred contact type Home Phone Cell Phone Text Email Appointment reminder calls/texts/emails may be made toName Phone NumberComplete 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 Status: Voluntary Court Order Civil Involuntary Criminal Involuntary Unknown Legal Custody: Self Parent/Grandparent Guardian Dept of Family Services Dept of Corrections/Juvenile Justice Bureau of Indian Affairs/Tribal Court Other Family Other please specify 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 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: Veteran Status: Yes No Homeless: Yes No Living Arrangements: Transient/Hotel Mission/Shelter 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 INSURANCE INFORMATION: Please select all that apply and include policy/ID#Please bring the appropriate insurance card(s) with you to your initial appointment MEDICARE Policy ID# MEDICAID Policy ID#VA: Is care for Sponsor Dependent Sponsor SSN or DOD Benefit #(11-digits NOT the DOD Military card ID #)Commercial InsurancePlan Name Policy ID#Group# TRICARE Policy ID#SELF PAY SELF PAY Needing Financial Assistance/Sliding Fee Secondary Insurance Coverage if applicable: MEDICARE Policy ID# MEDICAID Policy ID#VA: Is care for Sponsor Dependent Sponsor SSN or DOD Benefit #(11-digits NOT the DOD Military card ID #)Commercial InsurancePlan Name Policy ID#Group# TRICARE Policy ID#CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
