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Please fill out this intake form. Upon submitting this form you will be automatically directed to the REACH Intake and Screenings forms. These forms MUST be completed and signed online.
These forms need to be completed and signed before you start services with R.E.A.C.H. Counseling.
Then you will be contacted by R.E.A.C.H. to schedule your first appointment. Thank you for choosing R.E.A.C.H. Counseling.
R.E.A.C.H. New Client Intake form.
*
Indicates required field
Name
*
First
Last
Date of birth
*
Email
*
Phone Number
*
If client is under 18yrs, Parent/Caregiver Name
*
Clients age?
*
Less than 13
13-18
19-25
26-35
Over 36
Prefer not to say
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Gender Identity
*
Sexual Orientation
*
If Other please specify:
*
What type of service are you requesting (can select multiple boxes)
*
Individual Counseling - Adult
Individual Counseling - Child
Substance Abuse Recovery Counseling
Impact 360 - Fitness, Nutrition and Mental Health
Medication Management
Medically Assisted Treatment
Not sure but would like more information
How would you prefer to receive services
*
Face to Face (in person)
Telehealth (over the phone or computer)
No preference
Adult - Individual Counseling interested in additional services (Can select multiple options)
*
Family Counseling
Couples Counseling
Unsure would like more information
Child - Individual Counseling Services (can select multiple)
*
School based Counseling (counselor goes to collaborating schools)
Home based counseling (counselor will come to your home)
Office based Counseling
Telehealth (over the phone or computer
Family based Counseling
No preference
Unsure would like more information
Which County are you requesting services?
*
Highland
Ross
Green
Montgomery
Pike
Fayette
Clinton
Scioto
Not sure but would like more information
Substance Abuse Recovery Counseling (can select multiple options)
*
Intensive Outpatient SUD Counseling (admission into the IOP supportive housing and recovery services)
Out Patient SUD Counseling (recovery services not needing supportive housing)
Medical Assisted Treatment SUD
Unsure would like more information
If you are requesting R.E.A.C.H. Recovery do you need supportive housing?
*
Not sure would like more information
Yes
No
Are you interested in participating in any of the following groups? (can select multiple options)
*
Parenting Groups
Recovery Groups
Parents in Recovery Groups (Child care/groups provided for children)
Anger management groups
Self Esteem Groups
PTSD/Trauma Groups
Rise Groups (children and youth, age and gender)
Grief Groups
LGBTQIA+ Therapy/Support Groups
Life Skills groups
Codependency Groups
Sensory Groups
Anxiety / Stress Management Group
Brief Summary of Presenting Issue/s: (Please include current diagnoses and medications, if known)
*
NAME OF YOUR HEALTH INSURANCE COVERAGE (PUT NONE IF NOT INSURED)
*
Insurance Member ID
*
Would like assistance in exploring possible insurance options?
*
WOULD YOU BE SELF PAYING DUE TO NOT HAVING INSURANCE?
*
Yes
No
Were you referred to REACH? If Yes then by who?
*
Are you requesting a specific behavioral health Specialist, if so who?
*
How did you hear about this site?
*
Internet Search
Advertisement
Friend
Social Media
Other
Have you used any non prescribed prescription or non prescription drugs or alcohol within the past 30 days?
*
Yes
No
Upon submitting this form you will be emailed or texted a link for the Intake and Screenings needed. Please complete and sign these forms. Services will not be able to start unless they are completed and signed.
Thank you for choosing R.E.A.C.H. Counseling!
Submit
School Referral
ABOUT
CONTACT US
REACH Staff Directory
WELCOME TO R.E.A.C.H.
>
WHO WE ARE
REACH T-shirt Design
REACHOUT Community Center
R.E.A.C.H. PUBLISHING
REACH TV
Beloved Advocacy Center
>
Beloved About Us
Beloved Contact Us
Beloved Services
Beloved Survivors Corner
Church Partnership
FILLABLE FORMS AND SCREENINGS
>
REACH Intake Packet MH and SUD
IOP FACILITY AND PROGRAM FORMS
Mental Health Fillable Screenings Links
SUD SCREENINGS
REACH ROOMS SCHEDULER
>
South St Rooms Scheduler
Greenfield Center (Jefferson St.) Rooms Scheduler
Hillsboro Rooms Scheduler
Kingston Room Scheduler
R.E.A.C.H. Staff Portal
>
OLD Contractors onboarding information
TELL US ABOUT YOU
COUNSELING
TRAUMA COUNSELING
R.E.A.C.H. Counseling New Client Intake Forms
360Health
R.E.A.C.H. Restoration Counseling
>
Creative Counseling
Walking Life With you - CPST
School and Agency Counseling Referral
R.E.A.C.H. Recovery Counseling
TEEN Groups
TRAINING
The REACH Academy Courses
TRAINING & CONFERENCES
MAT7:12-TOOLBOX
HIRING
Blog