Medicaid Agency in Gresham, OR

Client Intake

A Medicaid Agency That Cares Like Family

We are currently at capacity and are not accepting new clients.

Client Intake

A Medicaid Agency That Cares Like Family

We are currently at capacity and are not accepting new clients.

Client Intake Form

Name of Person completing this form*
Parent/Guardian Name*
First Last
Address*
Street Address City State ZIP
Phone Number*
Email*
Name of Individual Receiving Services*
First Last
Age*
Date of Birth*
MM slash DD slash YYYY
Do you have a current ISP?*
- Yes
- No
CASE MANAGER CONTACT INFORMATION
Case Manager Name
First Last
Case Manager Phone Number
Email
How many hours per month are allotted for Direct Support Professional Services?*
May we contact your Case Manager/ Service Coordinator?
- Yes
- No
Comments
By submitting this form I understand that I am authorizing the following: *Out Of The Box Solutions to contact me about services. * Out Of The Box Solutions to share any pertinent information, history, and documentation with the Direct Support Professional that I have selected to provide services so that they are educated on the care that is needed. I understand that I may revoke this approval to share information by emailing [email protected].

CASE MANAGER CONTACT INFORMATION