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We need to know a few things that will allow us to check your eligibility and appropriateness for the services you are seeking at EOMHC that will align your needs to services available. This questionnaire is not for emergency crisis situations. If you feel that you are in a crisis or emergency situation, please dial 911, otherwise, please finish and submit this questionnaire; afterwards, we will call you to finish up on this screening and let you know your eligibility status.

If you would rather provide this information over the phone or in person, please contact us during regular business hrs at:
Phone: (918) 649-0011 - Address: 1011 N Broadway, Poteau, OK 74953

First - Middle Initial - Last Name *
Your answer
Maiden Name
leave blank if this does not apply
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Contact Phone # *
Your answer
Physical Address *
Your answer
Do you have Oklahoma Medicare, Medicaid, or Soonercare?
Social Security #
Your answer
For what problems are you seeking treatment?
Your answer
Please check all that apply that are problematic:
If you checked any of the above items, please explain them here.
Your answer
Does anyone else in your family need services?
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