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DOCUMENT CENTER |
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Here is the opening paperwork
required by Four County Mental Health Center for admission to services.
It is imperative that our center’s registration forms are filled out
accurately and completely before the appointment date. The client will
have to be rescheduled if we do not have the paperwork in hand at that
time. Please fax the completed forms back to us before the
scheduled appointment time. Thank you for your cooperation and for
choosing Four County Mental Health for your needs. |
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CONTACT
INFORMATION |
AIMS Adult Admission Form
AIMS Child Admission Form
Please make certain that all of the fields are properly checked or
filled out. |
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Independence
(620) 331-1748
Fax (620) 332-1940 |
Coffeyville
(620) 251-8180
Fax (620) 251-7400 |
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Billing Information Form-
Please fill in the date, client’s name, responsible party for billing
information, and have the appropriate representative sign at the bottom
of the form, as well as a witness from your agency. |
REGISTRATION FOR
CHILDREN IN FOSTER CARE |
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We need the
following releases for all foster children: |
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Foster Agency
Foster Parents
Primary Care Physician |
School District
Social & Rehabilitation Services (SRS) |
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Personal Information Form
- 2 pages; please ensure that all the required fields are filled out
with the patient’s current information. |
Send any history that is available
for the therapist to read over. Notify the foster parents of any
appointment times. |
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Permission for Initial
Treatment and Assessment Please enter in the child’s name, check the
“Other” box, and specify relationship. Verify that the bottom of the
form is correctly signed and completed by the patient’s representative
as well as a witness. |
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RELEASE OF INFORMATION FORMS |
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Please ensure that all of the X’s
and/or check marks are initialed or signed as indicated on the form.
Also, please have someone sign as a witness on each release. Releases
are not valid if they are not properly initialed and signed. |
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Release of Information Form
- Blank
Release of
Information Form - For PCP
Release of
Information Form - For Schools |
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