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.
IDENTIFYING DATA...
Consumers Legal Name
First, Middle Initial, Last Name
Your answer
Consumers Maiden Name (if female)
Your answer
Consumers Gender
Consumers date of Birth
MM
/
DD
/
YYYY
Consumers Age
Your answer
Consumers Social Security #
Your answer
Pay Source ID#
Your answer
Pay Source (Name)
Medicaid, Medicare, Private Insurance, Private Pay, etc...
Your answer
Consumers Home Phone
Your answer
Message or Work Phone
Your answer
Cell Phone
Your answer
Consumers Physical Address
include city, state, zipcode
Your answer
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