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Main Menu
Home
Programs
Healthy Place
Pursue Housing
Micro-Enterprise
Growing Kinship Connection
Resources
Resources
Careers
Media
Volunteer
Training & Development
Donate
Healthy Place (Mental Health & Wellness)
This program aims to be launched on April 1, 2022. We will reach out to applicants on first come first serve basis.
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Healthy Place (Mental Health & Wellness)
This program aims to be launched on April 1, 2022. We will reach out to applicants on first come first serve basis.
Name
First
Last
Date of Birth
Month
Day
Year
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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 Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Preferred Phone
Email
SSN
Race
African-American/Black
American Indian
Asian/Pacific Islander
Two or More Races
Unknown/Declined
White
Other
Gender
Male
Female
Non-Binary
Cis-Gender
Other
Marital Status
Single
Married
Widowed
Separated
Divorced
Other
Guardian?
Yes
No
If yes, Guardian needs to sign forms
Veteran/Military Status
Combat?
Yes
No
Receiving VA MH Services?
Yes
No
Referral Source
Reason for Referral
County of Residence
County of Financial Responsibility
Living Situation
(obtain release if necessary)
Insurance MA#
PMAP Co. /#
Other
Medical Coverage
Yes
No
If yes, need to complete ABN form
Education
Member of a Tribe
Yes
No
Live on Reservation
Yes
No
Requested Services
Interpersonal Communication Skills
Community Resource Utilization & Integration Skills
Crisis Assistance and Relapse Prevention Skills
Health Care Directives
Budgeting and Shopping Skills
Healthy Lifestyle Skills and Practices
Cooking and Nutrition Skills
Transportation Skills
Mental Health Symptoms Management
Medication Education
Medication Monitoring
Household Management Skills
Employment-Related Skills
Transition to Community Living
If current therapist working with client, has a DA or DA update been completed recently?
Yes
No
Case Manager
Medical Doctor
Psychiatrist
Therapist
Other
Emergency Contact Person/Phone
Income Source
Wages
GA
SSI
MSA
RSDI
Other
Annual Income
Employer
Source of Transportation
Today's Date
Month
Day
Year
Initial
