For individuals who meet DMH criteria, it is EdwinFairCenter’s policy that you must provide proof of income to avoid being charged full fee.

If you haveNO INCOME, bring one of the following:

Denial Statement from Unemployment Services

Statement from some other source, i.e., landlord, neighbor, family

member, etc., explaining lack of income and how expenses are paid

If you DO HAVE INCOME, bring one of the following:

Current paycheck stub for each employed person

Statement from employer(s)

Statement from Unemployment Services

If you are SELF EMPLOYED, bring one of the following:

Current income tax return

Statement from Accountant or Bookkeeper

If you have OTHER INCOME, bring the following:

Social Security statement

Other retirement income statement

Bank statement showing direct deposits

Interest earning statement

Child Support statement

Alimony statement

If you have MEDICAID, MEDICARE, OR PRIVATE INSURANCE, bring your identification card.

SPECIAL NOTICE

Missing the initial (intake) appointment may result in important services being delayed. Please call ahead of time if a scheduled appointment must be cancelled or rescheduled. Our phone number is: 580-762-7561 or 800-566-1343.

REQUEST FOR SERVICES

EDWIN FAIR COMMUNITY MENTAL HEALTH CENTER, INC.

1500 N. 6th St., Ponca City, OK 74601(580) 762-7561

1. Please provide the following information. ANSWER EVERY ITEM. Use "None" if item does not apply.

2. Check boxes as appropriate or fill in the blank for each question.

3. If request is for a CHILD, use the CHILD’S name and social security number.

Adult Child Male Female

APPLICANT NAME:

(Last) (First) (Middle Name) (Maiden Name)

Provider of Information:Applicant Other ______

APPLICANT ADDRESS:

(Street) (City) (State) (Zip) (County)

PHONE: /SSN:BIRTHDATE/Age:

(Home) (Work) (Month/Day/Year) (Age)

EMAIL ADDRESS: ______MAY ODMHSAS CONTACT THROUGH EMAIL?YES____NO____

BEST WAY TO CONTACT YOU?

MAY WE LEAVE A MESSAGE? ARE THERE CONFIDENTIALITY ISSUES?

DO YOU SPEAK ENGLISH? ______PREFERRED LANGUAGE: ______Other Languages Spoken:

DO YOU NEED ANY SPECIAL HELP/EQUIPMENT (e.g. Interpreter, Hearing Impaired)? _____ If yes, describe:

EMERGENCY / ALTERNATE CONTACT PERSON(Other than self)

(Name)

(Address)(Phone)(Relationship)

IF APPLICATION IS FOR A CHILD, LIST PARENT/GUARDIAN NAME:

Parent/Guardian address if different than child’s:

IF APPLICATION IS FOR A CHILD, WHOM DOES CHILD LIVE WITH?Mother Father Both Parents Other

IF GUARDIANSHIP, WHO HAS LEGAL CUSTODY?(Name of Individual or Organization)

Regarding Guardianships: Bring document showing proof, prior to first appointment.

(Address)(Phone)(Relationship)

REASON FOR CONTACT:

Suicidal (Check which apply) In the last 24 hours Last week Last month Longer than 1 month ago

Information / Referral

Crisis Intervention

Counseling for Self

Mental Health Assessment

Other

PRIMARY PERSON / AGENCY REFERRING YOU: Reason for Referral:

SECONDARY PERSON / AGENCY REFERRING YOU: Reason for Referral:

ARE YOU CURRENTLY INVOLVED IN COUNSELING ELSEWHERE?YesNo

If yes, what type? Where?

Describe briefly:

BRIEFLY EXPLAIN YOUR REQUEST (NEED FOR) OUR SERVICES:______

______

RACE: / MARITAL STATUS: / EMPLOYMENT:
White / Never Married / IF APPLICANT IS A CHILD, THE FOLLOWING
Asian / Married / APPLIES TO THE PARENT OR GUARDIAN:
American Indian / Divorced
Black/African American / Widowed / Occupation: ______
Native Hawaiian/Pacific Islander / Living as Married / Full-time Unemployed
Other: ______/ Separated / Part-time Not In Labor Force
Volunteer
ETHNICITY:
Hispanic/Latino / EDUCATION: / Homemaker Student
In School: Yes No / Retired Disabled
CURRENT RESIDENCE: / Years Completed: / Inmate Other: ______
Private Residence / Circle if you have:
No Home / GED or High School diploma / NAME OF EMPLOYER(S), IF ANY:
Residential Care Home
Institutional Setting / HANDICAP(Describe): / Consumer
Nursing Home
Community Shelter / Spouse
Other (Please Specify) ______
Parent/Guardian
LIVING SITUATION: / MILITARY STATUS:
Alone / Never Served / ANNUAL GROSS INCOME
With Family/Relatives / Active / OF RESPONSIBLE PARTY(S): $
With Non-Related Persons / Reserves / (From all sources, including child support, SSI, SSDI, TANF, etc.)
With batterer / Veteran
Retired/Disabled / NUMBER OF PEOPLE IN APPLICANT’S FAMILY
CURRENTLY HOMELESS: / DEPENDENT ON THIS INCOME:
No Yes, How long? ____ / Dates of Military Service:
Chronically Homeless: / ______to ______/ #
No Yes
Homeless in the last 3 years?
No Yes, # of times: ____
CURRENT BENEFITS: / EXPECTED SOURCE OF PAYMENT:
(Present Card with Request for Service)
SSI / None (Charity) / Medicare
SSDI / Self Pay / Medicare Supplement
TANF / Contract / Medicaid
Food Stamps / Private Insurance / SoonerCare
Social Security / Employer Insurance / Workers’ Compensation
Active Military or VA Benefits / Managed Care, HMO, PPO / Other Public Sources
Other (Please Specify) ______/ Employee Assistance Program (EAP) / Other Sources

******Medical Card and/or Insurance Information ******

Policy or Medical / Medicaid Card I.D. No. Group #:Effective Date:

Name of Insurance Company:

Address:

(Street)(City)

(State) (Zip) (Phone / Fax No.)

Has consumer, parent, or guardian obtained ANY REQUIRED approvals, pre-certifications, or contracts, etc.? Yes ____ No ____

****** Primary Insurance ******

Insured’s Name (if not the consumer): SS#:

Address (if different from consumer’s address):

Consumer’s Relationship to Insured (primary holder of insurance policy):

Insured’s Employer:

Mental Health

Within the last 90 days (3 months) have you had a significant period in which you have experienced:

1. / Serious depression (felt sadness, hopelessness, loss of interest, change of appetite or sleep pattern, difficult going about your daily activities)? / Yes / No
2. / Serious anxiety or tension (felt uptight, worried, unable to relax)? / Yes / No
3. / Being prescribed medication for psychological/emotional problem? / Yes / No
4. / Thoughts of harming yourself? / Yes / No
5. / Hallucinations (heard/seen things others don’t hear or see)? / Yes / No
6. / An attempted suicide? / Yes / No
7. / Experienced period of time when your thinking speeds up and you have trouble keeping up with your thoughts? / Yes / No
8. / No problems:

Tobacco Use

1. / Do you currentlyuse tobacco products? / Yes / No

Substance Abuse

During the past year (12 months) have you:

1. / Been preoccupied with drinking alcohol and/or using other drugs? / Yes / No
2. / Tried to stop drinking alcohol and/or using other drugs, but couldn’t? / Yes / No
3. / Had problems caused by drinking/using drugs, and you kept using? / Yes / No
4. / Need to drink and/or use more to get the same effect you used to? / Yes / No
5. / Drank alcohol and/or used other drugs more than you intended? / Yes / No
6. / Drank alcohol and/or used other drugs to alter the way you feel? / Yes / No
7. / Been addicted to prescription drugs? / Yes / No
8. / No problems:

Trauma

During the past year (12 months) have you:

1. / Experienced a traumatic event, natural disaster, war, accident, injury, loss of a love one? / Yes / No
2. / Had periods of time where you felt that you could not trust family or friends? / Yes / No
3. / Ever been afraid of your partner and/or a family member? / Yes / No
4. / Ever been hit, slapped, kicked, emotional or sexually hurt, or threatened? / Yes / No
5. / No problems:

Gambling

During the past year (12 months) have you:

1. / Felt the need to bet more and more money? / Yes / No
2. / Had to lie to people important to you about how much you gamble? / Yes / No
3. / No problems:

Child/Adolescent Section

1. / Are you feeling mad, sad, hopeless, nervous, or have you had a change in your sleeping, eating or school performance? / Yes / No
2. / Are you spending less time with friends, care less about your appearance, or feel alone? / Yes / No
3. / Get into trouble for acting up, fighting, setting fires, hurting animals or tearing up stuff? / Yes / No
4. / Have you ever experienced a very bad thing or person (traumatic event) where you continued to feel scared, worried, or nervous or even had nightmares that bothered you after it was all over? / Yes / No
5. / Are you using alcohol and/or illegal drugs including inhalants? / Yes / No
6. / Are you misusing any prescription medication or over the counter products? / Yes / No
7. / No problems:

______

Signature of Applicant (or parent/legal guardian) (Date)

EDWIN FAIR COMMUNITY MENTAL HEALTH CENTER

MEDICATION LOG

Consumer Name: ______Date: ______Chart#: ______

Primary Care Physician (name/address/phone): ______

List current medications with specific information as requested below.

Include over-the-counter medications and supplements.

Name of Medication / Dosage / Directions
(frequency & route) / Reason for Rx / Prescribing Physician & Phone / Pharmacy & Phone

Allergies: (Please list any and all. Use back side of sheet if necessary.)

Psychosocial Rehabilitation Services Questionnaire

ADULTS ( ages 21 and over) Please circle Yes or No

Have you ever been hospitalized for a Mental Health Issue or admitted to a Crisis Center

for Mental Health Issues? Yes No

If Yes, Name of Facility /date of hospitalization ______

(If answer is yes, consumer must answer yes to one of the below criteria to receive Rehabilitation Services at Edwin Fair)

Are you receiving SSI or SSDI due to a Mental Health disability? Yes No

Are you currently residing in a Residential Care Facility? Yes No

If Yes, name of facility______

Are you a currently in a Mental Health Court or Drug Court Program? Yes No

If Yes, name of program______

CHILDREN ( ages 6 through 20)

Haschild ever been hospitalized for a Mental Health Issue or admitted to a Crisis Center

for Mental Health Issues? Yes No

If Yes, Name of Facility /date of hospitalization______

Is child receiving SSI or SSDI due to a Mental Health disability? Yes No

Is child currently in a Mental Health Court or Drug Court Program? Yes No

Does child have a current Individual Education Plan for Emotional Disturbance? Yes No

If Yes, name of school______

Does child have a current 504 Plan for Emotional Disturbance? Yes No

If Yes, name of school______

Has child been referred for services by school psychologist, fully licensed psychologist or a psychiatrist due to

mental illness and/ or severe behavioral problems in class room? Yes No

If yes, name of professional who referred ______

Is child transitioning out of a Therapeutic Foster Care or OKDHS Level E Group home?Yes No

If Yes, name of home ______

______

Consumer Signature (Parent or Legal guardian signature if consumer is 17 or younger) Date

Forms/clinical forms/APPFORMPonca.docrev . 8/12/16File Under Administrative Tab