Waitlist- Community Chest Inc., Mental Health Counseling

Community Chest Inc.,

Mental Health & Substance Use Counseling
Contact Information
Please provide the information for the person in need of counseling services. Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Age*
Age of the individual seeking counseling services
Date of Birth

MonthDayYear
Date
Where does the individual live? *
If the individual is a minor, who is the legal guardian?
Legal Name:
Please bring all guardianship paperwork into the first session along with driver's license or other valid form of identification and proof of insurance
What is the safest way to contact you to coordinate services?*

PhoneEmailText
Victim of Crime
Has the individual been a victim of crime?*

YesNoUnknown
To find out more if the individual has been a Victim of Crime, please review here: List of Victimizations
If person has been a victim of crime, please select the type of victimization
If the individual has been a victim of crime, has a police report been made?

YesNo
Is the individual in need of a Victim Service Advocate?*

YesNoUnknown
If you are in need of a Victim Services Advocate, CCI provides in-house services with our expertly trained advocates. Kindly complete the Community Chest Inc: CCI Victim Services Intake Form. If we are unable to provide assistance, we have various resources available in the area for Victim Services.
Mental Health / Substance Abuse Evaluation
Is the individual in need of a mental health or substance abuse evaluation?*

Yes - Mental HealthYes - Substance AbuseNo
Is the mental health or substance abuse evaluation ordered by court?

YesNo
Who is requesting the evaluation?
Example: Name of Court, Judge, Doctor, Self, Officer
Evaluation Fees:

Non-Court-Ordered Evaluations: A fee of $250.00 is required for all non-court-ordered evaluations. Payment must be made in full prior to the scheduled evaluation appointment.
Funding Sources: Evaluations are not funded by grants. Payment may be covered by Medicaid or, by the court. In certain cases the evaluation may be covered through JPO.
Medical Insurance
Does the individual have health insurance?*

YesNoUnknown
What type of medical insurance does the individual have?
If you are a Medicaid member, kindly share your member ID:
We accept Medicaid and Medicare. You may qualify for some of our grant funded options. We offer a Sliding Fee Discount Program as we are committed to serving all clients regardless of ability to pay.
Client Counseling Preferences
Preferred office for counseling services, please select *
Preferred days for counseling*

MondayTuesdayWednesdayThursdayFriday
Preferred times*

9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM
Are you open to visiting another counseling office to minimize wait times if your preferred location is fully booked? Our counseling offices are located in Dayton, Fernley, Virginia City, and Yerington.

YesNo
If yes, please select which office
Is the individual willing to meet virtually (telehealth) to reduce their wait time? (computer, smartphone)*

YesNo
What is the individual seeking therapy for?*
Example: Anger issues, ADHD, Trauma work, DV, Substance Abuse, Worry, Phobias, PTSD, Eating Disorder, Group Therapy, etc.,
Suicidal Ideation Assessment
Have you ever had feelings or thoughts that you didn't want to live?*

YesNoFilling out as a referral
Do you currently feel that you don't want to live?**

YesNoFilling out as a referral
How often do you have these thoughts?*
When was the last time you had thoughts of dying?*
On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently?*

1

2

3

4

5

6

7

8

9

10

1 is Weak, 10 is Strong
If you are filling out the Suicidal Ideation Assessment as a referral, please type "unknown."

Please answer the following: *

	Yes	No
Do you feel hopeless and/or worthless?
Have you ever tried to kill or harm yourself before?
Is there anything that would stop you from killing yourself?
Filling out as a referral.

If you are facing a crisis situation, please call the following:

Suicide Hotline: 988
Crisis Support Services: 800-273-8255
NAMI Warmline: (18+): 775-241-4212 (call or text)
Domestic Violence/Sexual Assault Crisis Line: 775-720-0007
Is the individual interested in joining a counseling or peer support group?*

YesNo
How did you hear about Community Chest Inc.,? *
Who is completing this form? *
Example: John Smith , John Smith JPO Officer, Jane Doe SSP
Should be Empty:

Community Chest Inc.,

Contact Information

Victim of Crime

Mental Health / Substance Abuse Evaluation

Medical Insurance

Client Counseling Preferences

Suicidal Ideation Assessment