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Provider:_______________________
Application for Lee County
Subsidized Outpatient
Mental Health Services
Date of Application: _____/_____/______ Phone #(______)-______-________
Name of Applicant:_____________________________________________
Last First M.I.
Current Address:_______________________________________________________
Street A
__________________________________________ ____________ __________
_______________
City State Zip County
Social Security # :_ _ _/ _
_ / _ _ _ _ Birth Date: _ _ / _ _
/ _ _ _ _ Sex: _____
Parent Name (If applicant is under 18) or Guardian
(If applicable)
____________________________ _______________________________
Name Address
Ethnicity:
1) White, not Hispanic _____ 2) African American _____
3) Native American _____4) Asian or Pacific Islander
_____
5) Hispanic _____ 6)
Other (Biracial: Indochinese: etc.) _____
Marital Status:
1) Single, never married ____2) Married ____3)
Divorced ____
4) Separated ____5) Widowed ____
Veterans of US Armed Forces: Education:
Yes _____ No
_____ Years of School
(High School or GED=12) _____
Numbers of Person in Household: Adults _____ Persons under 18 _______
Applicant’s Living Arrangement:
1)
Lives alone _____ 2) Lives with relatives _____
2)
3) Lives with persons unrelated
to applicant _____
Monthly Gross Household Income:
Place of Employment_________________________________
Employment Wage Per Hour_______________
Number of Hours
Worked Per Week ________
Veterans Benefits…………………..$________
Public Assistance…………….$_________
Railroad/Other Pension…………….$________
Social Security Benefits……..$_________
Child Support………………………$________
Social Security Disability……$_________
Dividends, Interest…………………$________
Supplemental Security……….$_________
Other……………………………….$________
Resources:
1) Cash on hand………………$_________
4) Stocks/Bonds……………………$_________
2) Checking Account…………$_________
5) Trust Fund……………………….$_________
3) Savings Account/ C.D……...$_________
6) Other…………………………….$_________
Referred By:
1)
Self _____ 2) Family Member _____
3) Case Management _____
4) Community Corrections _____
5) Social Services Agency
6) Other ___________________________
Health Insurance: (Indicate all that apply)
Insurance Company Name
_____________________________________
Policy # ________________
Medicare # ______________________________
Medicaid (Title XIX) # ________________________
1) Insured by Employer _____
2) Other Private Insurance _____
3) Medicare _____
4) Medicaid _____
5) No Insurance _____
6) Other (explain)
__________________________________
Legal Settlement:
NOTE: LIST ALL PREVIOUS
ADDRESS’ UP TO THE POINT WHEN YOU
LIVED AT AN ADDRESS FOR
ONE YEAR WITHOUT RECEIVING ANY
SERVICES FOR MENTAL
ILLNESS, MENTAL RETARDATION AND/OR
DEVELOPMENTAL
DISABILITIES.
USE ADDITIONAL PAPER IF
NEEDED.
Please list where you have lived in the past,
begin with your current
address.
Current Address ________________________________________
What
dates have you lived at this address?
From
_________________ to __________________
Did you receive treatment or support services for
mental illness, mental
retardation
or developmental disabilities while at this address?
Yes
________ No________ (if yes)
What
were the dates? From ________ to ________
Provider(s)______________________________________________
Previous Address __________________________________________
What
dates did you live at this address?
From
_______________to ______________
Did you receive treatment or support service for
mental illness, mental
retardation,
developmental disabilities while at this address?
Yes
_________ No ________(if yes)
What
were the dates? From ________ to _________
Provider(s)________________________________________________
Previous Address___________________________________________
What
dates did you live at this address?
From
_______________to _______________
Did you receive treatment or support service for
mental illness, mental
retardation,
developmental disabilities while at this address?
Yes
________ No ________ (if yes)
What
were the dates? From ________ to __________
Provider(s)_______________________________________________
Signature: I hereby state
that the above information is accurate to the
best
of my knowledge. I understand that I
may be liable for the full
cost of services provided to me, which were paid
based on inaccurate
information,
which I may have supplied. Release: I HEREBY
AUTHORIZE THE LEE COUNTY CPC
AND/OR DESIGNEE TO
REQUEST ANY AND ALL INFORMATION TO VERIFY
APPLICATION DATA.
WE WILL CONSIDER THIS APPLICATION
WITHOUT REGARD TO RACE, COLOR, SEX, AGE, HANDICAPE,
RELIGION, NATIONAL ORGIN OR POLITICAL BELIEF.
Consumer or Guardian Signature
______________________Date:_______
ACKNOWLEDGMENT OF
RECEIPT OF NOTICE OF
PRIVACY PRACTICES
I,_______________________________________,
do hereby acknowledge
receipt of a copy of the Notice of
Privacy Practices, Policies, and Procedures.
_____________________________________ _____________________
Signature of Individual Date
In the event this
request is made by the individual’s personal
representative:
_______________________________________ __________________
Signature of Legal
Authority of
Personal Representative Personal Representative
Date_________________________
For Office Use Only:
Disability Group, Primary Diagnosis (Check One)
_______ (40) Mental Illness
_______ (41) Mental Retardation
_______ (42) Chronic Mental Illness
_______ (43) Other Developmental Disability
Service(s) Requested: 1) Individual Therapy
_____
2) Group Therapy _____ 3) Test_____
4) Psych. Evaluation
_____
5) Medication
Management _____
6) Other
___________________
CPC Office
Use Only: Service(s)
Approved:
1) Individual Therapy_____
Approved ________ Date_____________ 2) Group Therapy
______
Denied
________ Date_____________ 3) Test ______
Pending
________ Date_____________ 4) Psych. Evaluation______
5) Medication
Management ______
Lee
County CPC Office Signature
____________________
PL/3/07
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SERVICES & INFORMATION