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Please fill out the intake form below. Upon submitting this form you will be contacted by R.E.A.C.H. to schedule your first appointment. Thank you for choosing R.E.A.C.H. Restoration Counseling.
R.E.A.C.H. New Client Recovery 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:
*
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
How would you prefer to receive services
*
Face to Face (in person)
Telehealth (over the phone or computer)
No preference
Which County are you requesting services?
*
Highland
Ross
Green
Montgomery
Pike
Fayette
Clinton
Scioto
Not sure but 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
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
How did you hear about this site?
*
Internet Search
Advertisement
Friend
Social Media
Other
Were you referred to REACH? If Yes then by who?
*
Have you used any non prescribed prescription or non prescription drugs or alcohol within the past 30 days?
*
Yes
No
What is the date of your last substance use?
*
What substance/s did you use?
*
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
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