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Restore Outreach Center Intake Form
3966 Warrensville Center Rd.
Warrensville Heights, OH 44128
Phone: 440-340-5086
Fax: 440-340-5286
oh@restoreoutreachcenter.com
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Email
*
Your email
Please provide as much information as possible.
REFERRAL SOURCE
Name of Referral Source
*
Name of the person who referred you to Restore Outreach Center
Your answer
Date of referral
*
MM
/
DD
/
YYYY
DEMOGRAPHICS
This section is intended for information about the person receiving services
Last Name
*
Your answer
First Name
*
Your answer
Middle Name/Initital
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Gender
*
Female
Male
Transgender Female
Transgender Male
Prefer not to say
Other:
Required
Ethnicity
*
African
Alaskan Native
American Indian
Arabic
Asian
Australasian/Aboriginal
Bi-Racial
Black/African American
Carribbean
Chinese
Cuban
European/Anglo Saxon
Filipino
Guamanian
Hispanic or Latino
Indian
Japanese
Korean
Latin American
Melanesian
Mexican
Micronesian
Middle Eastern
Native Hawaiian or Other Pacific Islander
Other Asian
Other Hispanic
Polynesian
US or Canadian Indian
Vietnamese
White
Other:
Required
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
CONTACT INFORMATION
Parent/Guardian please skip the next 3 lines and apply personal information underneath section titled "Parent/Guardian". If you're applying for yourself, please complete this section.
Mobile Number
*
Your answer
Home/Alternative Number
Your answer
Email
Your answer
PARENT/GUARDIAN
Parent/Guardian please fill out this section with your personal information.
First and Last name
Your answer
Relation to client
Your answer
Mobile Number
Your answer
Email
Your answer
Is your address the same as client's?
Yes
No
Clear selection
EDUCATION
Parent/Guardian please complete this section. This section isn't applicable for all applicants.
Name of School
Your answer
Grade
Your answer
EMERGENCY CONTACT
If you're applying for yourself, please complete this section. Parent/Guardian please complete this section if emergency contact is not yourself.
First and Last Name
Your answer
Relation to client
Your answer
Mobile Number
Your answer
INSURANCE PROVIDERS
Please complete this section in full.
Healthcare Plan Provider
*
Your answer
Medicaid Number
Only apply 12-digit number to this line
Your answer
Social Security Number
Please provide a SSN if you do not have the client's medicaid number.
Your answer
PRESENTING PROBLEMS
Please check all that apply
*
Anxiety
Criminal Behavior
Constant Restlessness
Cutting Self
Defiance
Depression
Destructiveness
Difficulty Concentrating
Fidgety
Fighting
Fire Setting
Hurting Animals
Lying
Low Self Esteem
Phobias
Running Away
Suicidal
Temper Trantrum
Verbal Threats
Other:
Required
You've reached the end of the intake application.
R.O.C thanks you for your consideration!
Please anticipate a call from a team member to discuss the next steps. Have your insurance card readily available, thank you.
To be a leader by servicing others
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