Online Intake Forms

For all potential clients

During pre-admission screening, information is obtained to determine whether clients’ presenting complaints meet eligibility criteria, whether the individual or guardian desires treatment, and whether the Ontario County Mental Health Center (OCMHC) is an appropriate provider. 

Once we have received these forms, you will be contacted by clinic staff so we may obtain your insurance information and complete a fee agreement contract with you. You will then be registered in our electronic medical system and a clinical staff person will contact you to schedule your first screening appointment via telehealth. Please download, complete and sign, and return the forms via the upload link provided.

Also, during the pre-admission screening, OCMHC shall attempt to identify and obtain records from prior episodes of treatment and to obtain information from relevant concurrent health, social service, substance abuse, and mental health service providers. This information will assist us with the pre-admission screening and allow us to further assess clients’ presenting problems or symptoms. The clinical staff person will also be asking clients to answer questions and complete other assessment tools to determine specific symptoms or if a mental health diagnosis is present for which treatment at OCMHC would be beneficial.

For all clients to complete and return

• Review and save a copy of the Ontario County Notice of Privacy Practice regarding the clinic’s HIPAA practices. Then, please complete the Receipt of Notice of Privacy Practices form. This form will require a signature and the date.
• Download and review the Client’s Rights & Responsibilities form to learn about your rights and responsibilities as well as OCMHC’s attendance expectations for treatment and collaborations with, for example, the clinic’s Lakeview outreach care manager. This form will require a signature and the date.
• Please download, complete and sign the following authorization or written consent forms:
  • Authorization form for the client’s Primary Care Physician to obtain and/or release information about clients’ presenting problems and history, and to allow ongoing collaboration between the PCP and OCMHC for better care.
  • Authorization form for an Emergency Contact, so that we may contact this person in the event of a crisis or emergency situation, and/or to provide us another way for us to reach the client if we have been unable to do.
  • Authorization form for Lakeview Health Services, Inc, thus the client may be linked to OCMHC’s outreach case worker for support, advocacy, linkage to services/programs, or coordination of care.

For legal guardians / parents of minor child clients (between the ages of 5 and 17 years)

• Download and review the Authorization for Services of a Minor form to allow OCMHC to evaluate, treat, and provide services to minors. This form also requires a signature of a parent/legal guardian. Children who are above the age of 12 years must also provide a signature.

Instructions for Completing and Submitting Electronic Mental Health Intake Forms

1. All Mental Health Online Intake forms, including the above forms, can be found here.
2. Simply click on the link to the form you would like to complete and it will appear in your browser window. 
3. Locate the download button for your browser to download the form. 
4. Please save the form on your computer. Include YOUR NAME and the NAME OF THE FORM in the filename. For example: John R Doe-Receipt of Notice of Privacy Practices.
5. Forms were created using Adobe Acrobat and are best completed using Adobe Reader DC, a free application that can be downloaded here.
6. Once you have completed your forms, you will need to upload them so that our Mental Health staff may review them. We use a SECURE tool called ShareBase to accomplish this.
   
   To upload your completed forms, click this link to open the ShareBase upload window. Then, simply drag your files over the folder icon and drop. Next, click either ADD MORE FILES if you have more forms to upload or click UPLOAD if you are done. Your form files will be transferred into a folder that our staff (and no one else) can access. You will receive a confirmation message, UPLOAD COMPLETED letting you know that your files were successfully transferred. Click DONE.
7. If you realize that you forgot to complete a form(s), just follow the steps above to complete and submit the additional form(s). Forms do NOT need to be submitted all at once in a single upload.