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  City:  State: Zip:  Mailing Address (if different):   City: State: Zip:  Phone:   Ok to ID & leave a message: (circle one) Yes No Email:   Emergency Contact (name & number):   Ok to ID & leave message: (circle one) Yes No  \nServices seeking:  \n□ Individual Therapy □ Skill Development Groups □ Case Management  \n□ Individual Skill Building □ Peer Support □ Mental Health Assessment Only  \nInsurance Provider:   Insurance ID \\#:   Primary Care Provider & phone \\#:    \nCurrent Prescriptions & Schedule:  \n___________________________________________________  \nPrimary Race:  \n□ Alaskan Native □ Native Hawaiian or Other Pacific Islander □ American Indian  \n□ Asia □ Two or More Unspecified Races □ Black or African American Single Race  \n□ White  \n□ Other  \nEthnicity:  \n□ Puerto Rican □ Cuban □ Mexican □ Other Specific Hispanic  \n□ Hispanic (specific origin no specified) □ Not of Hispanic origin □ Unknown  \nTribal Member:  \n□ Burns Paiute Tribe □ Confederated Tribes of Coos, Lower Umpqua & Siuslaw  \n□ Confederated Tribes of Grand Ronde  \n□ Confederated Tribes of Warm Springs Tribe  \n□ Cow Creek Band of Umpqua Indians  \n□ Confederated Tribes of Siletz  \n□ Confederated Tribes of Umatilla  \n□ Not Applicable  \n□ Klamath Tribes  \n□ Coquille Indian  \n□ Other  \nMarital Status:  \n□ Married □ Separated □ Divorced □ Widowed □ Never Married  \nPregnant:  \n□ No □ Not Applicable □ Unknown □ Yes  \nTobacco Use:  \n□ No □ Yes □ Unknown  \n□ Chews □ Smokes □ Former Smoker □ Never Smoked □ Unknown  \nSubstance use, last 90 days:  \n□ No □ Unknown □ Yes  \nInterpreter:  \n□ Foreign Language □ Hearing Impaired □ None  \nMilitary/Veteran Status:  \n□ Yes, veteran & no specified branch of service □ No, but current or former guard/reserve military □ Yes, veteran & current or former guard/reserve military □ No  \n□ Yes, veteran & current or former active duty military □ unknown  \nLegal Status:  \n□ Aid & Assist (ORS 161.370)  \n□ Civil Commitment-30 day  \n□ Civil Commitment-90 day  \n□ Civil Commitment-180 day  \n□ DUII Diversion Client  \n□ DUII Convicted Client  \n□ Guardianship (Child Welfare)  \n□ Guardianship (Court)  \n□ Incarcerated  \n□ Involuntary Custody  \n□ Juvenile Psychiatric Security Review Board (JPSRB)  \n□ None  \n□ Parole  \n□ Post-Booking Jail Diversion  \n□ Pre-Booking Jail Diversion  \n□ Probation  \n□ Psychiatric Security Review Board (PSRB)  \n□ Unknown  \nNumber of arrests in the last month:   Number of arrests (lifetime):    \nNumber of DUII arrests in the last month:   Number of DUII arrests (lifetime):    \nEmployment Status:  \n□ Disabled (unable due to physical or psychological reasons)  \n□ Hospital patient or resident of other institutions  \n□ Sheltered/Non-competitive employment □ Full Time  \n□ Retired  \n□ Not in labor force  \n□ Part Time  \n□ Homemaker  \n□ Student  \n□ Unknown  \n□ Not Employed (seeking) □ Not Employed (not seeking) □ Other (e.g. volunteer work)  \nHighest grade completed in school (select one): 21  \nMonthly Income: $  Source of income:  \n□ Wages/Salary  \n□ None  \n□ Public Assistance  \n□ Unknown  \n□ Retirement/Pension/SSI  \n□ Disability/SSDI  \n□ Other  \nNumber in household (include yourself):   Number of minors in household (under 18):    \nLiving Arrangement:  \n□ Transient/Homeless □ Private Residence (with non-relative) □ Supported Housing (Scattered)  \n□ Foster Home □ Private Residence (other) □ Supported Housing (Congregate)  \n□ Room & Board □ Residential Facility (elderly) □ Unknown  \n□ Private Residence (at home) □ Residential Facility (substance abuse)  \n□ Private Residence (with relative) □ Alcohol & Drug Free Housing  \nReferred from (check all that apply):  \n□ ADES  \n□ Advocacy Group  \n□ Aging & People w/ disabilities  \n□ Attorney  \n□ Child Welfare  \n□ Circuit Court  \n□ Community Housing  \n□ Community-based MH &/or SA provider  \n□ Coordinated Care Organization (CCO) 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in the last 90 days, current prescriptions and schedule, and permission for identification and leaving messages.\"}]","Client Intake Form | PDF",1789842752]