top of page
Home
EE Classes
HARP Behavioral Health
Media Gallery
Events
Bike Ride
Donation
More
Use tab to navigate through the menu items.
Intake Form
Record ID
Participant Name
Intake date
Staff Initials
Insurance Company
Medicaid HMO / HARP
HMO Blue Option / Blue Choice Option / Premier Option / Blue Option Plus / Premier Option Plus
Community Care Medicaid
Healthy Choice / Liberty / Advocate Complete / Advocate
HealthPlus HP
UnitedHealthcare of New York
YourCare Health Plan Medicaid / YourCare Option Plus (HARP)
Enriched Health (HARP)
Personal Wellness Plan
Medisource
Medicaid Managed Care
MetroPlus Medicaid Managed Care / MetroPlus Enhanced (HARP) / MetroPlus Partnership In Care (PIC) HIV - SNP
Molina Healthcare of New York, Inc.
MVP Medicaid Managed Care / MVP Harmonious Health Care Plan
Medicare
Other (Please list below)
If other:
Date of Birth
What is your gender?
Male
Female
Transgender (male to female)
Transgender (female to male)
Other
Don't know
Refuse to answer
Not applicable
Current Address
Mailing Address (if different from current address)
Telephone Number
Is this a cell phone?
Yes
No
Please provide an alternative Phone number (trusted family member/friend who will take a message for you):
Email address
Can we contact you on social media?
Yes
No
Social media user name (please indicate which social media platform eg: Facebook, Instagram, Snapchat, etc):
Do you have a Primary Care Physician?
Yes
No
Name of your Primary Care Physician?
Address of your doctor's office?
Telephone number of your doctor's office?
Would you like us to make a referral to WISH clinic in Henrietta?
Yes
No
Do you have a past/active substance use history?
Yes
No
Don't know
Refuse to answer
Do you have a care manager?
Yes
No
Don't know
Refuse to answer
Have you been contacted by a care manager?
Yes
No
Would you like us to make a referral to a HCBS Yes Provider?
Yes
No
What services are you interested in?
Primary Care
Exercise classes
Spin
Yoga
Nutrition Workshops
Diabetes Prevention Program
Computer Classes
Recovery & Mental Health Workshops
Community Health Workers support
Relaxation Techniques
Other
Please describe what other services you need
Did the Client sign a Release form?
Yes
No
Submit Now
bottom of page
