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Information the Screener May Request
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Name
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Address
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Phone Number
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Birth Date
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Social Security Number
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A Brief Summary of the Problem or Need
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Insurance Information
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Household Income and Number of Persons in the Household (This is to
determine the amount of fee, if any, the individual will be responsible for.)
What Happens Next?
After this initial discussion, an appointment is scheduled to meet the
caller's needs (for example, counseling, a group program, vocational
services, housing, etc. In some cases, we may not be
able to provide the help being requested. In this event, the screener
or other staff member will help the caller to contact other local available
resources.
Will Anyone Know What I Talk About With
My Counselor?
We take your
privacy very seriously. By law, we are required to keep any information
about you or your treatment confidential. The only way we are permitted to
release information about you is if you personally approve it in writing.
The only exceptions to this policy are when child abuse or neglect are
suspected, when the court orders a release of information, or when a client
threatens harm to self or others and we feel an obligation to protect the client
or the community. To view our complete privacy policy, please click the
link below.
Protected Health Information Notice
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