Mifflin Sharks - Digital Intake Form

I. Client Information & Demographics

Youth Client Name

This field is required

Preferred Name/Nickname

Date of Birth

This field is required

Age

Age must be between 6-17

Social Security Number

This field is required

Gender Identity

This field is required

Pronouns

Primary Phone

This field is required

Email Address

Please enter a valid email address

Home Address

This field is required

City

This field is required

State

This field is required

ZIP Code

This field is required

School Name

This field is required

Grade

This field is required

Insurance Provider

This field is required

Policy Number

This field is required

Referral Source

II. Parent/Guardian Information

Primary Guardian Name

This field is required

Relationship to Youth

This field is required

Employer

Work Phone

Cell Phone

This field is required

Guardian Email

Mailing Address (if different)

Secondary Guardian (Optional)

Secondary Guardian Name

Relationship

Employer

Work Phone

Cell Phone

Email

Legal Custody/Guardianship

Joint

Mother Only

Father Only

Legal Guardian

Other

Please select custody arrangement

Upload Custody Documents (if applicable) Accepted formats: PDF, DOC, DOCX, JPG, PNG

III. Screening Form – Presenting Concerns

Reason for seeking services

This field is required

When did these concerns begin?

Areas affected (check all that apply)

School

Home

Peers

Mood

Behavior

Sleep

Appetite

Safety

Other

Current supports or services

Individual Therapy

Family Therapy

Medication

IEP/504

None

Other

Past/known diagnoses

Current medications

⚠️ Safety Concerns

Has your child ever expressed thoughts of self-harm or harm to others?

Yes

No

Please select an option

If yes, please explain

IV. PHQ-9 Depression Screening

Patient Health Questionnaire-9 (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things

Not at all

Several days

More than half the days

Nearly every day

This field is required

2. Feeling down, depressed, or hopeless

Not at all

Several days

More than half the days

Nearly every day

This field is required

3. Trouble falling or staying asleep, or sleeping too much

Not at all

Several days

More than half the days

Nearly every day

This field is required

4. Feeling tired or having little energy

Not at all

Several days

More than half the days

Nearly every day

This field is required

5. Poor appetite or overeating

Not at all

Several days

More than half the days

Nearly every day

This field is required

6. Feeling bad about yourself or that you are a failure

Not at all

Several days

More than half the days

Nearly every day

This field is required

7. Trouble concentrating on things

Not at all

Several days

More than half the days

Nearly every day

This field is required

8. Moving or speaking slowly, or being fidgety/restless

Not at all

Several days

More than half the days

Nearly every day

This field is required

9. Thoughts that you would be better off dead or hurting yourself

Not at all

Several days

More than half the days

Nearly every day

This field is required

How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

This field is required

V. GAD-7 Anxiety Screening

Generalized Anxiety Disorder-7 (GAD-7)

Over the last 2 weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious, or on edge

Not at all

Several days

More than half the days

Nearly every day

This field is required

2. Not being able to stop or control worrying

Not at all

Several days

More than half the days

Nearly every day

This field is required

3. Worrying too much about different things

Not at all

Several days

More than half the days

Nearly every day

This field is required

4. Trouble relaxing

Not at all

Several days

More than half the days

Nearly every day

This field is required

5. Being so restless that it is hard to sit still

Not at all

Several days

More than half the days

Nearly every day

This field is required

6. Becoming easily annoyed or irritable

Not at all

Several days

More than half the days

Nearly every day

This field is required

7. Feeling afraid, as if something awful might happen

Not at all

Several days

More than half the days

Nearly every day

This field is required

How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

This field is required

VI. Consent for Treatment Agreement

I, the undersigned Parent/Guardian, consent for my child to participate in the Day Treatment Program provided by Mifflin Sharks, which operates under certification and standards of the Ohio Department of Behavioral Health (DBH).

I give consent to the agency to provide treatment for my child which may include but is not limited to various therapies, transportation, psychosocial recreational activities, and/or medical intervention.

I understand that:

Day treatment is a structured, goal-oriented behavioral health program.
Services may include individual, group, and family therapy; skills development; psycho-education; and behavior management.
Services are voluntary and may be discontinued with written notice.
Confidentiality of records will be maintained in accordance with Ohio Revised Code 5122.31, HIPAA, and 42 CFR Part 2.
A treatment plan will be developed collaboratively and reviewed at least every 90 days.
I have received a copy of the agency's Client Rights and Grievance Policy.

Treatment Consent Signature

Signature is required

VII. Consent for Transportation

I authorize Mifflin Sharks to transport my child for purposes related to the Day Treatment Program, including travel to and from school, approved community activities, or therapeutic outings.

I understand that:

Transportation will comply with all agency and Ohio DBH safety policies
Vehicles are insured, and drivers are trained in safety and emergency procedures
I may revoke this consent in writing at any time

Transportation Consent Signature

Signature is required

VIII. Consent for Telehealth Services

Telehealth Services Agreement

I understand that:

Mifflin Sharks providers offer telehealth appointments for services
Video conferencing will not be the same as direct in-person visits
Telehealth has potential benefits including easier access and convenience
There are potential risks including interruptions, unauthorized access, and technical difficulties
Either party can discontinue if connections are not adequate

Potential Benefits:

Easier access and reduced travel barriers
Continuity of care when in-person services are unavailable
Inclusion of caregivers or schools in sessions when appropriate

Potential Risks:

Internet or equipment failures
Limited ability to observe nonverbal cues
Possible confidentiality risks related to technology

My Responsibilities:

Ensure a private, safe location for sessions
Avoid recording sessions unless mutually agreed upon
Report any safety or privacy concerns immediately

Telehealth Consent Signature

Signature is required

IX. Fees for Service

Service Rates

Service Type	Rate per Unit
Intake / Assessment	$125.28
Individual Therapy	$115.35
Day Treatment Group Therapy	$205.95 (per day)
CPST Group Therapy	$10.14 (per 15 min)
CPST Individual	$22.03 (per 15 min)

All services will be billed to insurance, and we offer sliding scale for self-pay clients.

Payment Method

Insurance

Self-Pay

Sliding Scale

Other

Please select a payment method

Fee Schedule Acknowledgment Signature

Signature is required

X. Emergency & Crisis Policy

⚠️ Important Safety Information

The safety of every youth in our program is our top priority.

If you are experiencing a mental health emergency, please use:

Call 911 if there is immediate danger to self or others
Call or text 988 for the Suicide and Crisis Lifeline (available 24/7 statewide)
Local Crisis Line: Lucas County Crisis CARE Line, available 24/7 at 419-904-CARE (2273)
ProMedica Russell J. Ebeid Children's Hospital Psychiatric Unit
2142 N. Cove Blvd., Toledo, Ohio 43606

Our program is not a 24-hour facility. Calls or messages received after hours will be addressed the next business day.

Emergency Procedures Acknowledgment Signature

Signature is required

XI. Your Rights as our Client

CLIENT RIGHTS

Mifflin Sharks implements policies and procedures to safeguard the rights of the persons served. These policies and procedures address the following:

Freedom from abuse, financial or other exploitation, retaliation, humiliation and neglect
The right of the persons served to have access to information pertinent to the person served in sufficient time to facilitate his or her decision-making, and to their own records
Informed consent or refusal or expression of choice and withdrawal of consent regarding service delivery, release of information, concurrent services, composition of the service delivery team and involvement in research projects, if applicable
Access or referral to legal entities for appropriate representation
Access to self-help and advocacy support services
Adherence to research guidelines and ethics when persons served are involved, if applicable
Investigation and resolution of alleged infringement of rights, and
Other legal rights
The involvement of all persons served in all aspects of their Individual Treatment Plans
The provision of services in a manner that is responsive to each person's unique characteristics, needs, and abilities
Methods by which the person served may review his or her record
Methods for obtaining authorizations for release of information
The prohibition of physical abuse, sexual abuse, harassment, and physical punishment
The prohibition of psychological abuse, including humiliating, threatening, and exploiting actions
The prohibition of fiduciary abuse
Mechanisms to facilitate access and referral to guardians, conservators, self-help groups, advocacy services, legal services
The right of the person served to be provided with information to facilitate decision making
The right of the person served to express his/her preferences regarding choice of case manager, therapist, or other service provider
The use of crisis intervention procedures, including seclusion or restraint
Written procedures governing the use of special treatment interventions and restrictions of rights
The parameters of confidentiality
Mechanisms to communicate these policies in an ongoing manner that is competitive

GRIEVANCE PROCEDURE

If you have concerns or complaints:

First, speak with your counselor or case manager
If unresolved, contact the Client Rights Officer
You may file a written grievance at any time
All grievances will be resolved within 20 calendar days
You may also contact outside agencies including Ohio DBH and Ohio Legal Rights Service

Additional Grievance Information:

Any staff member will assist you in filing a grievance upon your request. All grievances, including a copy of the grievance, documentation reflecting the process used and resolution/remedy of the grievance and documentation, if applicable, of extending the time period for resolving the grievance beyond twenty (21) calendar days will be kept on file two years from resolution and will include a copy of the grievance, documentation reflecting the process used and resolution/remedy of the grievance and documentation, if applicable, of extending circumstances for extending the time period for resolving the grievance beyond twenty (21) calendar days.
Within three (3) working days of receiving the grievance, Client Rights Officer will provide each grievant with written acknowledgement that includes:
1. The date the grievance was received
2. A summary of grievance
3. An overview of grievance investigation process
4. A timetable for completing the investigation and notification of the resolution, and
5. The treatment provider contact person's name, address and telephone number.
If a problem cannot be resolved at a staff level, any client or family member may initiate a grievance at his/her discretion by requesting a grievance form from any staff person. Should the client need assistance in completing the grievance form, Client Rights Officer will assist in the preparation and filing of a grievance. All grievances will be submitted to the Owner.

Client Rights Officer: Kelly Morales
Phone: 419-283-3018
Address: 735 South St. Clair, Toledo, Ohio 43609

Client Rights Acknowledgment Signature

Signature is required

XII. Privacy Practices & Confidentiality

NOTICE OF PRIVACY PRACTICES

Your Rights:

Right to receive a paper or electronic copy of this Notice
Right to file a complaint if you believe your privacy rights were violated
Right to request restrictions on uses and disclosures
Right to receive confidential communications
Right to inspect, copy, and amend your PHI

How We Use Your Information:

For Treatment: To provide behavioral health and medical services
For Payment: To bill and collect payment for services
For Healthcare Operations: To improve quality of care and services

42 CFR Part 2 - Confidentiality of Alcohol & Drug Abuse Client Records

Federal laws protect information about alcohol and drug treatment. We cannot disclose that you receive services or any identifying information unless:

You consent in writing
The disclosure is allowed by court order
For medical emergencies, research, or audits by qualified personnel

Privacy Officer: Emily Boston
Phone: 419-708-0841

Privacy Practices Acknowledgment Signature

Signature is required

XIII. Digital Signatures & Final Acknowledgment

By signing below, I acknowledge I understand all sections of this intake packet, including consent forms, telehealth and transportation policies, fees, and emergency protocols. I have had the opportunity to ask questions and receive clarification regarding my child's participation in the Day Treatment Program under the Ohio Department of Behavioral Health (DBH) standards.

Parent/Guardian Signature

Signature is required

Youth Signature (if applicable)

Date

Date is required

✅ You're almost done!
Please review all information before submitting.

XIV. ODM Standard Authorization Form (ROI) — Form A

Authorization for Release of Information

This form authorizes the release of protected health information in accordance with HIPAA and Ohio Revised Code requirements.

SECTION I — Client Information

First Name

Middle Initial

Last Name

Date of Birth

Social Security Number

Address

City

State

ZIP Code

SECTION II — Disclosing Entity & Recipient Info

Disclosing Entity Name

Entity Address

Telephone Number

Entity City

Entity State

Entity ZIP

Recipient Name

Recipient Contact Information

SECTION III — Disclosure Details

Reason for Disclosure

Health Information to Be Disclosed

Release Start Date (mm/dd/yyyy)

Release End Date (mm/dd/yyyy)

SECTION IV — Expiration & Signatures

Expiration Date or Event

Method of Delivery

Paper

Fax

Electronic

Individual Signature

Date Signed

Personal Representative Signature

Representative Date

Representative Relationship

XV. FORM B — Consent for Release of Substance Use Disorder (Part 2 Program) Information

Consent for Release of Substance Use Disorder Information

This form provides consent for the release of protected substance use disorder information in accordance with 42 CFR Part 2 regulations.

SECTION I — Client Information

First Name

MI

Last Name

Date of Birth

Social Security Number

Address

City

State

ZIP Code

SECTION II — Disclosing Entity & Recipient Type

Disclosing Entity (Part 2 Program) Name

Entity Telephone Number

Entity Address

Entity City

Entity State

Entity ZIP

Recipient Type

Named Individual

Named Third Party Payer

Named Treatment Provider Entity

Named Non-Treatment Provider

Named Individual Participant(s)

Named Treatment Provider Entity Participants

Description of Group or Class of Provider Participants

Recipient Contact Information

SECTION III — Disclosure Details

Reason for Disclosure

Health Information to Be Disclosed

Release Start Date (mm/dd/yyyy)

Release End Date (mm/dd/yyyy)

SECTION IV — Expiration & Signature

Expiration Date or Event

Method of Delivery

Paper

Fax

Electronic

Individual Signature

Date

Personal Representative Signature

Date

Representative Relationship

XVII. Client Handbook Download

📖 Client Handbook

By completing the orientation checklist above, you have acknowledged receipt of all the information contained in our Client Handbook. You can now download and save the Client Handbook to your own files for future reference.

Important: Please save this handbook to your personal files as it contains important information about your rights, responsibilities, and program policies.

XVI. Client Orientation Checklist 2025

Client Orientation Checklist

This checklist ensures all clients receive comprehensive orientation to Mifflin Sharks' programs, policies, and procedures. Each item must be reviewed and initialed by both client and staff.

Client Name

This field is required

Date

This field is required

Orientation Items

Hours of operation Client Initials:

Organizational Ethics Statement Client Initials:

Rules, Regulations, and Expectations Client Initials:

Client rights & responsibilities Client Initials:

Financial obligations / arrangements / fees Client Initials:

Complaint, grievance, and appeal procedures Client Initials:

Expectations for family involvement Client Initials:

Access to after-hours services Client Initials:

Identification of service coordinator Client Initials:

Ways client gives input re: quality, outcomes, satisfaction Client Initials:

Copy of program rules (restrictions, consequences, regaining privileges) Client Initials:

Confidentiality policies Client Initials:

Federal SUD Confidentiality Law — 42 CFR Part 2 Client Initials:

Site & safety orientation (exits, emergency equipment, etc.) Client Initials:

Use of tobacco products Client Initials:

Purpose & process of assessment Client Initials:

How Individual Plan is developed & client involvement Client Initials:

Course of treatment / services Client Initials:

Aftercare, transition, discharge criteria & procedures Client Initials:

Response to identified risks Client Initials:

Policy on seclusion & restraint Client Initials:

Infectious disease education (HIV, Hep B/C, TB, universal precautions) Client Initials:

Education on Advanced Directives Client Initials:

Policy regarding illegal/legal/prescription medications brought in Client Initials:

Policy regarding weapons brought in Client Initials:

Expectations about required legal appointments or sanctions Client Initials:

Identification of therapeutic interventions / sanctions / incentives Client Initials:

Intent / Consent to Treat Client Initials:

Behavioral expectations Client Initials:

Standards of professional conduct Client Initials:

Requirements for mandated reporting / follow-up Client Initials:

Signatures

Client Signature

Signature is required

Client Signature Date

Date is required

Staff Signature

Signature is required

Staff Signature Date

Date is required

Secondary Guardian (Optional)

⚠️ Safety Concerns

Patient Health Questionnaire-9 (PHQ-9)

Generalized Anxiety Disorder-7 (GAD-7)

Telehealth Services Agreement

Service Rates

⚠️ Important Safety Information

CLIENT RIGHTS

GRIEVANCE PROCEDURE

NOTICE OF PRIVACY PRACTICES

42 CFR Part 2 - Confidentiality of Alcohol & Drug Abuse Client Records

Authorization for Release of Information

SECTION I — Client Information

SECTION II — Disclosing Entity & Recipient Info

SECTION III — Disclosure Details

SECTION IV — Expiration & Signatures

Consent for Release of Substance Use Disorder Information

SECTION I — Client Information

SECTION II — Disclosing Entity & Recipient Type

SECTION III — Disclosure Details

SECTION IV — Expiration & Signature

📖 Client Handbook

Client Orientation Checklist

Orientation Items

Signatures

Form Submitted Successfully!

Submission Error

WELCOME, LET US INTRODUCE OURSELVES!!!

🌱 Mission Statement

Helping Children Thrive In Childhood—Mind, Body, and Spirit

🧠 Program Description

• Mental Health & Wellness Programs

• Mentorship & Coaching

• Youth Summer & After-School Programs

• Competitive Dance Team (Ages 6–16)

• Recreation Center & Game Rooms

• Free Transportation & Meals

• Community Giving & Outreach

📋 Summary of Purpose

Secondary Guardian (Optional)

⚠️ Safety Concerns

Patient Health Questionnaire-9 (PHQ-9)

Generalized Anxiety Disorder-7 (GAD-7)

Telehealth Services Agreement

Service Rates

⚠️ Important Safety Information

CLIENT RIGHTS

GRIEVANCE PROCEDURE

NOTICE OF PRIVACY PRACTICES

42 CFR Part 2 - Confidentiality of Alcohol & Drug Abuse Client Records

Authorization for Release of Information

SECTION I — Client Information

SECTION II — Disclosing Entity & Recipient Info

SECTION III — Disclosure Details

SECTION IV — Expiration & Signatures

Consent for Release of Substance Use Disorder Information

SECTION I — Client Information

SECTION II — Disclosing Entity & Recipient Type

SECTION III — Disclosure Details

SECTION IV — Expiration & Signature

📖 Client Handbook

Client Orientation Checklist

Orientation Items

Signatures

Form Submitted Successfully!

Submission Error