EOMHC's Mental Health Screening
The form below is the first step in determining eligibility for receiving services at EOMHC. If you have any questions or need help filling out this screening, please do not hesitate to call and ask for help at 918-649-0011. If you prefer, you can call us and we can take the information over the phone.
Once you complete this screening, Give us a call to confirm that EOMHC received you data. A clinician will contact you within 2 business days and let you know of your eligibility status. If eligible, we will set an appointment with you to begin the intake process. If you needs cannot be met at EOMHC, we will help you find alternative and appropriate referral sources for your level of care.
Consumers Legal Name
First, Middle Initial, Last Name
Consumers Maiden Name (if female)
Consumers date of Birth
Consumers Social Security #
Pay Source ID#
Pay Source (Name)
Medicaid, Medicare, Private Insurance, Private Pay, etc...
Consumers Home Phone
Message or Work Phone
Consumers Physical Address
include city, state, zipcode
Page 1 of 6
Never submit passwords through Google Forms.
This form was created inside of EOMHC.
Terms of Service