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Outpatient Mental Health Clinic Application for Services

Steps

  1. 1. Step One
  2. 2. HEALTH HABITS
  3. 3. FAMILY HISTORY
  4. 4. ADL & RISK FACTORS
  5. 5. BIRTH & DEVELOPMENT HISTORY
  6. 6. PRESENT PROBLEMS OR SYMPTOMS
  • Step One

    1. OC Seal
    2. Orange County Department of Mental Health Application for Services
    3. Clinic*
    4. General Information
    5. (No abbreviations or nick names)
    6. Sex
    7. (street address)
    8. (if different from street address)
    9. Race
      (select all that apply)
    10. Ethnic Group
      (select all that apply)
    11. Place of Birth
    12. Marital Status
    13. Living Arrangements
    14. Number Living In Household
      (Please list below beginning with self)
    15. SELF
    16. Veteran
    17. Military Related Disability
    18. Contact Person
      (if other than client)
    19. Is This The First Time You Have Received Services At This Clinic?
    20. Reasons For Contact
    21. Issues You Want To Address In Treatment
    22. Have You Ever Been Treated For Emotional Or Mental Health Problems
    23. Please list all
      (including past treatment at Orange County Mental Health Clinic)
    24. Education
    25. N/A
    26. N/A
    27. If Currently in School
    28. Education Type
    29. Permission To Contact After Discharge
    30. Permission To Treat A Minor
    31. For Such Treatment As Recommended By One Of Your Staff. This May Include The Prescribing Of Medication By Your Medical Staff, Only With My Knowledge.