Adult SPOA | Intake

Skip to Main Content
Required fields are marked with an asterisk* and must be completed.

Applicant Information

First Name:*

Last Name:*

Date of Birth:*

Social Security #:

Medicaid #:

Gender:*

Address:*

Apt. #:

City:*

State:*

Zip:*

XXXXX-XXXX

Telephone:

Citizenship:

Ethnicity:

Primary Language:

Employment Status:

Highest Education Level:

Custody Status Of Children:

Current Living Situation:

Insurance and Financial Information: Currently Receives

Referral Source and Current Treatment Providers
If Referral Source is different than the current Treatment Provider(s), add Treatment Provider information in the Outpatient Treatment Provider section:

Name:*

Phone:*

Agency:

Fax:

Address:

Program Referred From:

Relationship to Referral Source:

Psychiatric Information

Diagnosis:*

Maximum 560 Characters

Risk Assessment:

Cruelty to Animals
Suicidal Behavior
Fire Setting
Severe Violence
Homicidal Behavior
Sexual Offense
None

Current Medications: Please List

Maximum 560 Characters

Outpatient Treatment Provider

Agency:

Program:

Contact:

Telephone:

Substance Abuse History: Please List Drugs of Choice

Maximum 560 Characters

Length of Time Recipient Has Been Substance Free:

Criminal Justice - Current Status

Does client have current involvement with the court/criminal justice system?

Number of arrests/incarcerations in past year:

Number of lifetime arrests:

Reason for arrest:

Date of most recent arrest:

Assisted Outpatient Treatment

Does the person have court ordered AOT under Kendra's Law?

Is an AOT under Kendra's Law currently being pursued?

Case Management Service Requested

Care Management
Peer
Mobile Outreach Team/Transitional Outreach Program

If specific program requested, describe here:

ACT Services Requested?

If specific program requested, describe here:

Residential Services Requested

Supervised Community Residence
Supported Single Room Occupancy (SRO)
Supervised ID/DD Community Residence
Apartment Treatment Programs
Supervised Co-Occurring Community Residence
Supported Housing
Rental Assistance Program Individual - documentation of homelessness required
Rental Assistance Program Family - documentation of homelessness required

If there is a geographic/community preference, describe here:

Maximum 190 Characters

Recipient Requests

Maximum 280 Characters

Community Oriented Recovery and Empowerment (CORE) Services The services below can be requested for individuals who are Health and Recovery Plan (HARP) enrolled.
Please contact the individual's Managed Care Organization to determine if he or she is HARP enrolled.
Requests are not a guarantee of receipt of services.
The Single Point of Access and provider agencies will review all individuals referred for appropriateness.

Community Psychiatric Support and Treatment (CPST)
This service includes mobile therapy and treatment services. This cannot be used as an outpatient treatment provider.
Agencies providing this service include:

    CHOICE
    HDSW
    MHA
    The Guidance Center
    No Preference

Psychosocial Rehabilitation (PSR)
   This service provides skill building to support living, working, learning, and socializing.
   Agencies providing this service include:
    CHOICE
    CLUSTER
    HDSW
    MHA
    Search for Change
    The Guidance Center
    No Preference

Empowerment Services - Peer Support
   This service provides support from individuals with lived experience.
   Agencies providing this service include:
    CHOICE
    HDSW
    MHA
    The Guidance Center
    No Preference

Family Support and Training (FST)
   This service provides education and training for an individual's family of choice.
   Agencies providing this service include:
    CHOICE
    HDSW
    MHA
    Search for Change
    The Guidance Center
    No Preference

Upload Clinical Information *

Clinical information including psychosocial and psychiatric evaluation is required. At least one document must be uploaded before submitting.

Total attachments should not exceed 10 MB

Signatures Recipient Signature:

BY CHECKING THE "I AGREE" CHECKBOX BELOW, YOU, THE RECIPIENT, AGREE THAT YOU HAVE READ, UNDERSTAND, AND AGREE TO ALL THE TERMS AND CONDITIONS DESCRIBED HEREIN.

CLICKING ON THE "I AGREE" CHECKBOX WILL BE THE SAME AS IF YOU HAD SIGNED YOUR NAME ON PAPER.

RECIPIENT:* I AGREE

DATE:

Referring Party Signature:

IF YOU ARE FILLING OUT THE FORM FOR SOMEONE ELSE, BY CHECKING THE "I AGREE" CHECKBOX, YOU ASSERT THAT YOU HAVE PERMISSION TO DO SO FROM THE RECIPIENT LISTED HEREIN.

CLICKING ON THE "I AGREE" CHECKBOX WILL BE THE SAME AS IF YOU HAD SIGNED YOUR NAME ON PAPER.

REFERRING PARTY:* I AGREE

DATE: