Mental Health | FORM TEST | OhioGuidestone

OhioGuidestone Request for Services Form

Who is filling out this form? *

Self
Parent/Guardian
Other Entity

Client Information

Former Client

Client Last Name *

Client First Name *

Client's Preferred Name

Date of Birth *

Social Security Number *

Social Security Number

Gender *

Street Address *

City *

State *

Zip Code *

Please enter your 9 digit zip code in the xxxxx-xxxx format. If you do not know your +4 zip code, enter your address on this page at the USPS website.

County of Residence

Do you give permission to receive text messages for scheduling purposes if you have shared your cell phone number below? *

Yes
No

Phone (cell/home) *

What type of phone is this? *

Cell
Home

Email *

Email

Marital Status *

Marital Status

Race *

Race

If Other Race, Please Specify

Ethnicity *

Hispanic or Latino/a/e origin
Not Hispanic or Latino/a/e origin

Ethnicity

Hispanic or Latino/a/e origin
Not Hispanic or Latino/a/e origin

Religion *

Religion

If Other Religion, Please Specify

Primary Language *

Primary Language

If Other Language, Please Specify

Parent/Guardian Name (if client is a minor) *

First

Last

Parent/Guardian Name (if client is a minor)

First

Last

Relationship *

Relationship

Emergency Contact Name *

Emergency Contact Name

Emergency Contact Phone Number *

Emergency Contact Phone Number

Emergency Contact Email

Emergency Contact Relationship *

Emergency Contact Relationship

County Worker Name, if applicable

First

Last

County Worker's Phone, if applicable

For clients involved with Children's Services

Referral Date *

How Did You Hear About Us? *

If Other, Please Explain *

Referral Source

This section is to be completed when another agency or entity is making the referral

Referral Source *

Please begin typing the name of the referral source and select accordingly. If the referral source is not in the drop down, please type "other" and you will be given an option to add it.

If Other Referral Source, please specify *

Fiscally Responsible County

Referent Name *

First

Last

Contact Phone *

Referent Email *

Program Referred To

Program Level

Specific Contract Name

Complete if not listed under Program

Reason(s) for Referral (check all that apply) *

Additional Information

Funder/Payor/Contract

Permission obtained to verify benefit eligibility? *

Yes
No

Funding Type

Household Size *

Please enter the number of people living in your household

Monthly Gross Income *

Please enter the total monthly income amount before taxes for all household members

Source of Income *

Medicaid Managed Care Plan *

Medicaid Care ID# *

Medicaid MMIS# *

Private Insurance Company *

Employer *

Policy Holder Name *

Policy Holder Relationship *

Policy Holder Date of Birth *

Policy Holder Social Security Number *

Policy Holder Address *

Policy Holder Phone *

Policy Number *

Group *

Customer Service Phone Number *

Name of Funding Source *

Contact Name *

Contact Phone *

Medicare ID# *

Part *

MyCare Plan Name *

MyCare ID# *

Customer Service Phone Number *

Nearest OhioGuidestone Region *

Service Location Preference *

Office
Telehealth

If you have selected School for your Location Preference and you do not see School District and School options below, we do not offer School Services in your area.

School District (Tuscarawas)

School (Newcomerstown Exempted Village)

School (New Philadelphia City Schools)

School (Tuscarawas Central Catholic)

School (Strasburg-Franklin Local School District)

School (Garaway Local Schools)

School (Dover City Schools)

School (Indian Valley)

School (Tuscarawas Valley Schools)

School (Claymont City Schools)

School District (Summit)

School (Akron Public Schools)

School (Alternative School APS)

School District (Medina)

School (Brunswick)

School (Highland)

School (Buckeye)

School (Black River)

School District (Lorain)

School (Amherst Exempted Village)

School (Elyria City)

School (Firelands Local)

School (Keystone)

School (Lorain City)

School (Lorain County JVS)

School (Lorain County Community College)

School (North Ridgeville)

School (Sheffield/Sheffield Lake)

School (Charter Community Schools)

School (Private Schools)

School (Vermilion Local Schools)

School District (Erie)

School (Sandusky City Schools)

School (Perkins Local School District)

School District (Lucas)

School (Toledo Public School)

School (Charter School)

School (Springfield Local Schools)

School District (Henry)

School (Northwest Ohio Educational Service Center)

School (Liberty Center Local Schools)

School District (Ottawa)

School (Genoa Local Schools)

School District (Williams)

School (Bryan City School District)

School District (Fulton)

School (Evergreen Local School District)

School District (Cuyahoga)

School (Berea City Schools)

School (Brooklyn City Schools)

School (Charter Schools)

School (Cleveland Metropolitan School District)

School (East Cleveland)

School (Euclid City Schools)

School (Garfield Heights City Schools)

School (Lakewood City Schools)

School (Olmsted Falls City Schools)

School (Parma City Schools)

School (Parochial Schools)

School (Richmond Heights Local Schools)

School (South Euclid Lyndhurst City Schools)

School District (Crawford)

School (Galion City School District)

School District (Delaware)

School (Big Walnut Local Schools)

School District (Fairfield)

School (Lancaster City School District)

School (Berne Union School District)

School (Pickerington City School District)

School (Fairfield Union School District)

School (Bloom Carroll School District)

School (Amanda Clearcreek Local School District)

School (Fairfield County ESC)

School (Liberty Union School District)

School District (Franklin)

School (Hamilton Local School District)

School (Whitehall City School District)

School (KIPP Columbus)

School District (Licking)

School (Granville Exempted Village Schools)

School District (Madison)

School (West Jefferson Local School District)

School District (Marion)

School (Pleasant Local School District)

School (Marion City School District)

School (Ridgedale Local Schools)

School (River Valley Local Schools)

School (Elgin Local Schools)

Grade

Teacher

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If you'd like, you can PRINT A COPY OF THIS RECORD before submitting this form. You can also request a copy from your OhioGuidestone provider.