Adult SPOA Application
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Required fields are marked with an asterisk
*
and must be completed.
Applicant Information
First Name:
*
Last Name:
*
Date of Birth:
*
Social Security #:
Medicaid #:
Gender:
*
Select
Female
Male
Non-Binary
None of these
Refused
Transgender - presents as Female
Transgender - presents as Male
Unknown
Address:
*
Apt. #:
City:
*
State:
*
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Corolina
North Dokota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
*
XXXXX-XXXX
Telephone:
Citizenship:
Select
US Citizen
Permanent Resident
Resident Alien
Undocumented Immigrant
Ethnicity:
Select
Hispanic or Latino
Non Hispanic or Latino
Refused
Unknown
Primary Language:
Select
English
Spanish (And Creoles)
American Sign Language
Arabic
Chinese
French (And Creoles)
German
Greek
Hindi-Urdu
Hungarian
Italian
Japanese
Korean
Native North American
Polish
Portuguese
Russian
Scandinavian
Tagalog
Vietnamese
Yiddish
Refused
Unknown
Other
Other:
Employment Status:
Select
Full Time:35 Hours or more per week
Part Time: Less than 35 Hours per week
Disabled
Homemaker
Inmate of Institution
Retired
Self-Employed
Sheltered Employment: e.g. Shelter Workshop,etc.
Unemployed
Unemployed: Seeking Work
Other
Other:
Highest Education Level:
Select
Kindergarten
Pre-School
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade/GED
College (2 or 4 years)
Post Graduate
No Formal Education
Other Certification
Vocational
Custody Status Of Children:
Select
No children
Children are all above 18 years of age
Minor children currently in client's custody
Minor children not in client's custody but have access
Minor children not in client's custody - no access
Number of Children:
Current Living Situation:
Select
Adult Custodial Care
Adult Home
Apartment
Condominium
Correctional Facility
Crisis Residence
Halfway House
Hospital
Intensive/Supportive Comm Res
Nursing Home
NYS OMH Comm Res
NYS OMH RCCA
OASAS Residence
Own Home
Psychiatric Hospital
Rehabilitation Center
Rented Home
Rented Room
Shelter
Street Homeless/Unstably Housed
Supported Housing
Supervised Community Residence (CR)
Unknown
With Family
Other
Other:
Insurance and Financial Information:
Currently Receives
Aid for Dependent Children
Alimony
Child Support
Disability Insurance/Worker's Compensation
Family or Relative
Food Stamps
General Relief/Welfare
Medication Grant
Pension
Public Assistance
Retirement Pension
Savings or Investments
Social Security Disability Insurance (SSDI)
Social Security Retirement
Supplemental Security Income (SSI)
Trust Fund
Unemployment Compensation
VA Benefits
Wages/Salary Income
Worker's Compensation
None
Other
Other:
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:
Select
ACT team member
Advocate
Care Manager
CORE Services Provider
Crisis support
General Practitioner
HIV Provider
Home Health Aide
Housing Provider
MH Practitioner
Other Health Practitioner
Peer Services
Physician
Primary Physician
Psychiatrist
SUD Counselor
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?
Select
Yes
No
Incarcerated-Jail
Incarcerated-Prison
CPL 330.20/730
Probation
Parole
TASC/MHATI
Other
Other:
P.O.Name:
Telephone:
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?
Select
Yes
No
Is an AOT under Kendra's Law currently being pursued?
Select
Yes
No
Case Management Service Requested
Care Management
Peer
Mobile Outreach Team/Transitional Outreach Program
If specific program requested, describe here:
ACT Services Requested?
Select
Yes
No
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
Additional Document Attachments:
Total attachments should not exceed 10 MB
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
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:
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