Name: First, Middle Initial, Last Age and Birthdate Phone #:
Address, City, State, Zip and County
Group #:
Insurance Company Have another Ins? If so, list:
Marital Status : Insurance ID #:
Outpatient Service you want:
Select Insurance
Beaumont Classic
Blue Cross
Blue Care Network
Cash paying
Cigna
City of Westland
DMC
Great Lakes
GM Careline
Health Plan of MI
Medicare
MCare
Molina/Compcare
Molina/Omnicare
Midwest
UBH
Value Options
Other
Outpatient Services
Assessment Only
Mental Health
Substance Abuse
DLAD Assessment
Trying to schedule with a specific therapist?
Appt Request:
M, T, W, TH, F, ST
Who Referred you to HTC? Reason for referral?
Referral Source
Court/Probation
Family/Friend
EAP/Job
Insurance Co.
Shool
Self
Website
Other
NOTIFICATION IN CASE OF EMERGENCY: Name Address phone # Relationship: Are you currently receving Mental Health services? If yes, where?
# Lifetime psychiatric
Are you currently receiving Substance Abuse (SA) services? If yes, where?
Any Known Psychiatric Diagnosis :No Yes If yes, list
# of outpatient treatments:
Ever been diagnosed with ADD
# Previous SA treatments:
Currently drink alcohol/ use drugs? If yes list Name and frequency and route?
History of IV Drug Use: No or Yes
Currently on any medications: No Yes If yes:
# of HTC Admits?:
Family currently receiving services here at HTC: No Yes If yes, who:
For ADULT Candidate: Legal Guardian?: No Yes If so, Guardian Name: Address: Telephone:
For CHILD Candidate: Parent/Guardian Name: Address: Telephone:
Does candidate need an interpreter?
Candidate have difficulty with Hearing: Reading: Writing: Yes or No?
Primary Language: English Yes No If no, primary language?
# of arrest in last 5 years. If yes, list
Any Past Military Services?
Please list any Comments you may have:
Today's Date:
Your email address
You will be contacted by telephone, within 24 hours with your scheduled date/time.
CONFIDENTIALITY : State and Federal laws protect confidentiality for services received at HTC.
