ACP Intake Face Sheet

Client First Name

Client Middle Initial

Client Last Name

Client Date of Birth

(MM/DD/YYYY)

Client Social Security Number (###-##-####)

Other Gender Description

Client Street Address

Client City

Client County of Residence

Client State (Abbreviated)

Client Zip Code

Parent or Guardian Name (Enter "None" if Client is an adult.)

Preferred Phone Number

Preferred Email address

Contact Permissions (Check all that apply.)

You may email about services and appointments

You may text about services and appointments.

You may leave a voicemail about services and appointments.

Please provide the name of your preferred Medical Practice and/or Primary Care Physician in case of emergencies.

If none, enter "None". Example: Cleveland Clinic, Dr. Smith

Please provide the name of an emergency contact person

Relationship to emergency contact person

Emergency Contact Phone Number (XXX-XXX-XXXX)

Name of School Attending (if applicable)

Consents and Client Rights:

By signing below, I consent to behavioral health treatment by Anazao Community Partners (ACP). I have been advised of the risks and benefits of treatment. I have been advised of my rights as a client or parent/guardian of a client. I understand that ACP uses an Electronic Health Record (EHR) as part of the PartnerSolutions Health Informatics Consortium (PSHIC). I understand that private information may be shared with other partners in this consortium through the EHR. I understand that in order to determine my eligibility for public funds to pay for services, private information will be disclosed to the Mental Health and Recovery Board (MHRB) of Wayne and Holmes Counties and to the Ohio Department of Mental Health and Addiction Services (OMHAS) through the PSHIC, NextGen EHR, SmartCare, Medicaid Information Technology System (MITS) or Managed Care claims systems. I understand that any records that are specifically related to substance use are protected by federal law (42 CFR Part 2) and cannot be disclosed without my written consent and that federal rules restrict the use of this information to criminally investigate or prosecute me. I understand that each client at ACP has a number of rights and that these include, but are not limited to: being treated with respect, dignity, autonomy and privacy; being served in a humane setting; being informed of condition, services and alternatives; the right to refuse any service; being served with a current and collaborative treatment plan; the right to confidentiality of and personal access to treatment records; freedom from discrimination and the right to file a grievance. I understand that the Quality Assurance Specialist serves as the agency’s Client Rights Officer and that they can be reached at 330-264-9597. I understand that I can review this information in full detail at www.anazaocommunitypartners.org.

Client Electronic Authorization (if 18+) or Parent/Guardian (if Client is under 18)

Date

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