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Page 1 of 3
Revised: 6/2/2021
Name: Case #:
Date:
315 W. McLain
Sherman TX 75092
Intakes are by appointment only. For information regarding intake process, please call (903) 957-4701
Texoma Community Center Office Phone #: (903)957-4701 Available Monday-Friday 8:00 a.m. – 5:00 p.m.
Crisis line: 1(877)277-2226 Available 24 hours a day, 7 days a week
Hearing Impaired Crisis Line: 1(800)735-2989 (TDD/TT) Available 24 hours a day, 7 days a week
• Intake appointments are available by appointment only during business hours, except for holidays – New
Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and the day after,
Christmas Eve, and Christmas Day – or any other day specified by Texoma Community Center.
• Priority is given to continuity of care, such as, hospital discharges, and people transferring
from other community centers.
• Required paperwork AND all required documentation must be completed and returned to reception
window prior to intake appointment being scheduled. Paperwork can be completed while at the office or
can be taken home and returned to reception window once completed
• Required paperwork can be given to you by Texoma Community Center staff at the reception
window or you can find a printable version on the Texoma Community Center’s website,
http://www.texomacc.org/mental-health-2/
• See the checklist on Page 2 for all required documentation for both Adults and Children.
• In Reference to Financial Documentation that is required on Page 2. If there is not income for the adult
seeking services, or the parent of the child seeking services, please have the person that is supporting
either the adult seeking services or the parent of the child seeking services fill out the attached form on
page 3 titled: Financial Assistance Verification Worksheet
• If you were referred, please bring this form to Open Intake, and show reception. This will help them
when determining who you saw and what you are needing.
Comments:
If referred, Referring Staff’s Name & Credentials/Title:
Page 2 of 3
Revised: 6/2/2021
Name: Case #:
Documents Needed for Open Intake
Please bring the following information with you when you come for Open Intake
For Adult Intake
***Do not bring children to the Open Intake that are 12 years old or younger, please make other
arrangements for any child in your care. ***
Medical Insurance information, Medicaid, Medicare, Medicare Part D, MCO or other insurance.
Social Security Card
Driver’s license or ID Card
Proof of residence such as a utility bill
Proof of income:
• Four most recent pay stubs or statement from employer stating income for any financially
responsible household member
• SSI or SSDI award letters
• Retirement documents showing amounts
• Proof of public assistance including food stamps
• W-2 or latest tax return filed
Copies of prescriptions or pill bottles
Medical records in relation to mental/behavioral health (hospital discharge paperwork, previous
evaluations, etc)
For Child Intake
Medical Insurance information, Medicaid, Medicare, Medicare Part D, MCO or other insurance or
parents’ Medical Insurance information IF the child is covered on that insurance.
Parent’s Driver’s license or ID Card
Proof of residence such as a utility bill
If the parents are divorced, a copy of the divorce decree designating custodial rights is required. This
must be returned prior to a diagnostic evaluation and follow up services.
Proof of Parent’s income:
• Four most recent pay stubs or statement from employer stating income for any financially
responsible household member
• SSI or SSDI award letters
• Retirement documents showing amounts
• Proof of public assistance including food stamp
• W-2 or latest tax return filed
Birth Certificate
Psychiatric Records or psychological testing if any
Financial Assistance Verification Worksheet
***THIS FORM IS REQUIRED TO BE FILLED OUT FOR
INDIVIDUALS WITH NO INCOME***
DATE: _______________________
ADDRESS: _____________________________________________________________
PHONE #: ______________________________________________________________
This form is needed to help us determine what financial assistance __________________
(Name of Consumer)
receives from you. Please tell us what you provide for this person and if you expect the
arrangements to change.
Please check below which items you help with:
Food Gas for Car
Clothes Medical Bills
Cigarettes Probation Fees
Toiletries Phone
Rent Cable
Utilities Other
Car Payment Car Insurance
Prescriptions Doctor Visits
Transportation
Other: _______________________________________________________________
How much would you say you spend in a month’s time to provide these things for this
person? $1 to $50 $51 to $100 $101 to $200
$201 to $300 $301 to $400 $401 plus
Do you expect this arrangement to change, and if so, when?________________________
For what reason? _________________________________________________________
_________________________________ _____________________ ____________
Signature of Person Completing Relationship to consumer Date
Revised: 6/2/2020 Page 3 of 3
Name:
Case #:
click to sign
signature
click to edit
Name:_______________________________ Case ID:____________ MDCD#:_____________
CRC#-5 Revised 1/25/18 File in Medical Hx Tab Page - 1 - of 2
TEXOMA COMMUNITY CENTER MEDICAL DATA SHEET
And Transportation Authorization Form
Today’s Date: ____________ DOB: Age:
Address:
***Please include your Physical Address, City, State, and Zip Code
Phone #(s):
Social Security #:
Insurance Information:
Medicaid #:
Medicare #:
Third Party Insurance: #:
Other:
Emergency Contact Information:
Name: LAR: Y N – If Yes, Type:
Relationship: Contact Information:
Address: Home Phone #:
Work Phone #:
Cell Phone #:
ADVANCE DIRECTIVE for MH Services ON FILE?: YES NO Email:
Allergies: Adaptive Aids:
DRUG:
TYPE:
NO
DENTURES/PARTIAL
HEARING AID
FOOD:
GLASSES CONTACTS
OTHER:
WHEELCHAIR WALKER
OTHER:
LIST ANY CURRENT MEDICAL CONDITIONS/DIAGNOSES AND DATE OF ONSET:
List any other serious illness, injuries, hospitalizations or procedures that have occurred and date:
Prohibited Activities due to medical status ________________
TYPE/NAME
YES
NO
DATE OF ONSET
ARTHRITIS
BLEEDING
DISORDER/BLOOD CLOTS
GOUT
CONJESTIVE HEART
FAILURE
GERD/ACID
REFLUX/STOMACH ULCER
HIGH CHOLESTEROL
LIVER DISEASE
PREGNANT
TYPE/NAME
YES
NO
Date of Onset
DIABETES
HYPERTENSION/ELEVATED
BLOOD PRESSURE
HEART DISEASE
ASTHMA/COPD
CEREBRAL PALSY
SPEECH IMPAIRMENT
PHYSICAL LIMITATIONS
MENTAL ILLNESS
OTHER:
SEIZURE DISORDER
TYPE: Grand Mal
Petit Mal Other
Frequency:
Neurologist:
Name:_______________________________ Case ID:____________ MDCD#:_____________
CRC#-5 Revised 1/25/18 File in Medical Hx Tab Page - 2 - of 2
SUBSTANCE USE HISTORY
Current use of alcohol Yes No
Current use of illicit drugs Yes No
Past use of alcohol Yes No
Past use of illicit drugs Yes No
SUBSTANCE
START DATE
LAST USE
PATTERN OF USE
# Of Alcohol drinks Per day: ______; Per week: _______; Per month: _________ Last Use Date: __________
Have you ever been treated for any type of substance use? Yes No
Location(s) and date(s): ________________________________________________________________________
Any Mental/Emotional Concerns?: Yes No If yes:
PAST TREATMENT FOR MENTAL/EMOTIONAL CONCERNS
LOCATION
DATE(S)
PROBLEM/DIAGNOSIS
Is there a family history of Mental Illness? Yes No If yes:
Relationship to You
Diagnosis
Relationship to You
Diagnosis
In the event of a medical or psychiatric emergency necessitating medical attention of any variety, I hereby consent and give permission to TEXOMA
COMMUNITY CENTER or any of its representatives at their sole discretion to call 911, my emergency contact listed on this form, and/or my primary
care physician listed on this form. In addition, I hereby consent and give permission to TEXOMA COMMUNITY CENTER or any of its representatives
when medically necessary to use CPR, rescue breathing, abdominal thrusts, and first aid procedures. I also give my permission to EMS personnel to
provide all medically necessary treatment when they are called on my behalf.
I understand that TEXOMA COMMUNITY CENTER will not be financially responsible or liable for any emergency treatment I receive.
I give my permission for TEXOMA COMMUNITY CENTER staff to transport me, my child, or my ward to and from TCC programs and/or any other
necessary events, programs, facilities or community activities.
____________________________
Signature of Individual/ LAR/ or Parent of Minor Individual/LAR/Parent printed name Date
_________________________
Staff’s Signature Staff printed name/credentials Date
PRESCRIBED MEDICATION(S):
DOSAGE
USE
SIDE EFFECTS
PRESCRIBING DR.
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
Page 1
Is Client Homeless:____________________________
___________________
________________
_________________
______________
_______________________
____________________________
_____________________
___________________________
____________________________________
___________________________________________
______________________________________________ _____________________________________________
_____________________________
_________________________________________________
______________________________
______________________________________
_________________________________________
_______________________________________________________________________________________________________
____________________________
_______________________________
_______________________________
___________________ _____________________
____________________________
_____________________ _______________________________________________________________
______________________________________
_____________________________________
________________________________________________________________________________________________
________________________________________ __________________________________________________
_________________________________________________
______________________________________
________________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Date________________ Case#_______________ Medicaid#_______________
Page 2
_____________________________
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_____________________________________________________
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_________________________________________________________________________________________________________________
____________________
_______________________
_______________________________________________________________________________________________________
_________________________________________________________________________________________________________________
______________________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________________________________________________
_____________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________ __________________________________________________________________
________________________________
_____________________________________________________
_________________________________________
_________________________________________________
_____________________________________
_____________________________________________
__________________
_______________________ ______________
_____________________________
_______________________________________________________________________________________________________
__________________________________________________________________________________________________________________
CRC#-81 Updated 5/11/18 Main\AMH\Consents, R&R Page 1 of 3
Consumer’s Name:________________________ Case #:__________ MDCD#:___________ Date:_______
TEXOMA COMMUNITY CENTER (TCC) INFORMATION AND TREATMENT AGREEMENT FOR MENTAL
HEALTH SERVICES
Your relationship with the Center and its representatives is professional and therapeutic. In order to preserve this relationship,
it is imperative that the Center or its representatives not have any other type of relationship with you and/or your family.
Personal and/or business relationships undermine the effectiveness of the therapeutic relationship. The Center and its
representatives care about helping you and are not in a position to befriend you and/or the members of your family, or to have
a social, business, or personal relationship with you and/or your family members. Gifts, bartering, and trading services
between you or your family and the Center is not appropriate.
APPOINTMENTS/CANCELLATIONS
You will be seen as close to your appointment time as possible, but an appointment insures a place on the schedule. Time
seen is based on schedule, emergencies, consultations, etc. Being late to an appointment may cause your place on the
schedule to be cancelled. Cancellations must be received at least 24 hours before the scheduled appointment. You are
responsible for calling to cancel or reschedule the appointment. Also, please be advised that if you are going to be more than
15 minutes late for an appointment, you may have to reschedule, or wait for a no-show later that day, as a courtesy to those
who have been scheduled after you.
CONSENTS AND INFORMATION RELATED TO SAFETY
• Children cannot be left unattended by the legally authorized representative at any Texoma Community Center
facility. If a child is left unattended, the Center is obligated to report such conduct to the Texas Department of
Family and Protective Services.
• The Center staff may refuse to see any one that presents for a session under the influence of illicit drugs and/or
alcohol.
• Smoking is only allowed in designated areas, and during activities only at designated times. Smoking is never
allowed inside the facility or any of the vehicles.
• Respect the property and rights of others. Property includes the Mental Health Services building, all contents in the
building/grounds, and the Center vehicles. Rights of others include peers, staff, and community.
• Incoming calls for consumers are not accepted to protect confidentiality. Personal phone calls will be limited to 3
minutes. Do not intentionally listen to others’ calls. Respect their privacy.
• Any inappropriate conduct including but not limited to violence, threats, cursing, screaming, physical aggression, or
use of illicit drug and/or alcohol intoxication by either consumers or persons accompanying them may be reported to
law enforcement, and will result in the termination of the appointment.
• In the event that the Center staff reasonably believe that you and/or your family member(s)or friend are a danger,
physically or emotionally, to themselves or any other person, TCC may contact medical and law enforcement
personnel, including, but not limited to: a general hospital, the local emergency room, a psychiatric hospital, the
courts, a judge, protective agencies (Child Protective Services or Adult Protective Services), primary care physician,
the police, emergency medical service (ambulance), and/or 911.
INFORMATION FOR INDIVIDUALS TRANSPORTED BY CENTER STAFF
• Do not ask staff to drive you somewhere that has not been pre-approved. Transportation will only be authorized to
transport consumers to medical appointments. The Transportation Supervisor or Program Manager must approve any
exceptions.
• No eating or drinking on the vans, vehicles, or carpeted areas of Mental Health. No trash is to be left on the vans,
vehicles, or TCC property TCC is not responsible for lost personal items.
• If weather conditions cause unsafe road conditions, skills training activities and transportation will be cancelled.
• While being transported, you must stay in your seat and keep your seat belt buckled until the van or vehicle comes to
a complete stop. Do not distract the driver while they are transporting. Any violations of safety rules on the van or
Center cars will result in a written incident report. If continued violations occur or consumer
• Refuses to comply with safety rules, the consumer may be suspended from being transported by MH staff.
CRC#-81 Updated 5/11/18 Main\AMH\Consents, R&R Page 2 of 3
Consumer’s Name:________________________ Case #:__________ MDCD#:___________ Date:_______
INFORMATION PERTAINING TO INDIVIDUALS PARTICIPATING IN GROUP SKILLS TRAINING
• Those attending Group Skills Training are expected to stay until posted hours are over, unless there is an emergency.
If you leave the Group Skills Training, you will need to advise Skills Training staff. If you leave against the advice
of the staff there will be an incident report filed, and you may be in jeopardy of suspension.
• You are expected to stay awake during Skills Training activities.
• While attending activities at TCC, you must clean up after yourself in all areas
TCC discourages borrowing, lending or giving of money or other items (such as cigarettes) at any time. When
everyone contributes money for a group meal or goes out to eat, you may choose to bring your own food. Do not ask
for food or money from others.
• If you are sick or have cold/flu like symptoms, do not come to Group Skills Training. If you have been ill for an
extended time, or in the hospital, you will need a release from your doctor to return to Group Skills Training. If the
hospital was Behavioral Health Center or North Texas State Hospital, you will need to attend your after care
appointment with your case manager before returning.
• You are expected to wear modest attire with all undergarments to Skills Training activities. Examples of
inappropriate clothing are short skirts, short dresses or short shorts; clothing that is tight or sheer; and clothing that is
generally offensive to others. This applies to men and women.
• Proper hygiene will be maintained while participating in Skills Training activities or programs. Bathe daily before
coming to the program. Offensive body odors may be cause for removal from skills training for the day. Mental
Health staff may refuse to transport consumers with offensive body odor.
AFTER-HOURS EMERGENCIES
Emergencies are urgent issues requiring immediate action. After hours, callers will reach an answering service; the on-call
worker will return the call as soon as possible to provide crisis intervention services. A Qualified Mental Health Professional
(QMHP) is on call when the Center’s offices are closed, and can be reached twenty-four-hours, seven-days-per-week at the
following number:
1-877-277-2226
For consumers who have a hearing impairment and need access to after-hours crisis services, they should first contact Relay
Texas in order to facilitate communication between the consumer and the answering service at: 1-800-735-2989 (TDD/TT).
The on-call staff will then call the individual back using Relay Texas to facilitate communication.
CRITERIA FOR DISCHARGE
Discharges from Mental Health Services may occur for any of the following reasons:
• You and program staff mutually agree to the termination of services.
• You move outside of Grayson, Fannin, or Cooke counties.
• You achieve the outcomes on the Care Plan.
• You no longer meet the criteria for services, or the services are no longer medically necessary.
• You do not respond to treatment, and are not willing to participate in your treatment; whereas, a continuation of
services could be interpreted as fraudulent, infringement of your rights, or unsafe conditions for staff.
• You are non-compliant with appointments. Non-compliance is defined as two consecutive cancellations, or four
cancellations within 90 days, or two no shows within 90 days. Cancellations may be medically excused. No excuses
accepted for no-shows.
• If the assigned Mental Health staff has not been able to contact you, or heard from you within 30 days.
• You are expected to follow the Mental Health Services Guidelines. Disruptive behavior will not be tolerated for the
safety of other consumers. After reasonable effort is made to correct inappropriate conduct, you may be removed
from the program for that day, and possibly suspended until the treatment team reviews the situation, or have services
discontinued.
You have the right to appeal a denial, termination or suspension of services. To appeal this decision, please contact the
Human Rights Officer at: (903) 957-4874
CRC#-81 Updated 5/11/18 Main\AMH\Consents, R&R Page 3 of 3
Consumer’s Name:________________________ Case #:__________ MDCD#:___________ Date:_______
TREATMENT AGREEMENT INFORMATION
• I agree that I will participate in the planning, care, assessment, evaluation, treatment, or other services that are
considered medically necessary and advisable.
• I understand that the results of services including assessment, evaluation, treatment, or other service cannot be
guaranteed as to result or cure and the results of any such services are largely dependent on my participation.
• I understand and agree to follow the treatment recommendations of TCC and its representatives once these have been
agreed upon with TCC, its representatives, and me.
• I understand that I may refuse to receive treatment, or any portion of treatment, at TCC I also understand that the use
of illicit drugs and/or alcohol may be dangerous for persons receiving medications, and consequently, the physician
may refuse to prescribe for me under such circumstances. I further understand that I may be asked to obtain a drug
test and results consistent with illicit drug or alcohol abuse or misuse may be grounds for the denial of medications.
• If services for my family member or me include medications, I understand I must take the medication(s) just as the
physician has prescribed. I understand that I should not increase, decrease, stop, or otherwise alter medication(s)
without consent from the prescribing physician.
• I understand that I should notify TCC or its representatives at least one week in advance if my family member(s) in
services or I need a refill of the medication(s) prescribed by TCC’s physician(s). I understand that if I fail to notify
TCC or its representatives of this, I may be without medications for a brief period of time.
• I understand that I should notify TCC or its representatives, if I become pregnant, if symptoms become worse, if
other concerns such as side effects, if suicidal or homicidal ideation or intent or plan is experienced, if I decide to
seek treatment elsewhere, or if I am dissatisfied with services received from TCC.
• I understand that if I miss two scheduled Dr’s appointments in a row, that I may have to go without my medications
until I can get back in to see the Dr.
• I understand that if I have Medicaid, I would usually have to see the Dr. before I may obtain a prescription for a 90-
day supply of medications.
• I specifically consent for the Center and its representatives to contact me by telephone and/or mail, including leaving
a message via answering machine or voice mail.
• I understand I may bring a family member to my Dr.’s appointment or treatment planning appointment if I feel it
would be helpful, or if the Center staff recommend such action, and I (or your LAR) am willing to sign releases of
information for those persons, as long as their presence is not disruptive to my treatment.
• I understand that inappropriate behavior from either me or my friend or family member attending my appointment,
such as: threatening, cursing or other behaviors that can be construed as disrespectful and hostile toward staff that
are not due to mental illness will result in immediate termination of the appointment, and if necessary contacting the
police.
By signing below, I certify that I understand and agree to the above information presented to me. I have been given ample
opportunity to ask questions about any information that is unclear to me. I have been offered a copy of this document.
Consumer’s or LAR’s Signature Consumer/LAR Printed Name Date
Staff’s Signature Staff printed Name/Credentials or Title Date
Comments:
Name: MDCD #:
Page 1 of 1
CRC- 97 Revised: 4/16/18 File in: Consents, R&R
RECEIPT OF DOCUMENTS ACKNOWLEDGEMENT FORM
Date:
Please place your initials beside each document that you have signed and/or received a copy and explanation of.
If the document listed is not applicable to you, please write N/A in the blank.
Notice of Privacy Practices (Initially only, except if changes occur)
Charges for Community Services Brochure
Treatment Agreement and Center Information Form (Original to be filed in chart)
Rights Booklet
By signing this form, I (the undersigned consumer, child, adolescent, parent, and/or legally authorized
representative) acknowledge and certify that I have been given a copy of each named document that I have
placed my initials by, listed above. Further, I certify that I have read or have had each document read to me in
my primary language and that I understand the terms and information contained therein. Ample opportunity
has been offered to me to ask questions and seek clarification of anything unclear to me.
Signature of Consumer Consumer Printed Name Date
Signature of LAR (If applicable) LAR Printed Name and relationship to Consumer Date
By signing below, I certify that I, and Texoma Community Center representative, have explained and provided
a copy of the above listed documents to the consumer and/or LAR.
Signature of Staff Staff Printed Name & Credentials/Title Date
Name: ____________________________ Case #:_________________________ MDCD#:________________________
This Authorization is Hereby Revoked at my Request
_____________________________________________
Signature of Individual/LAR Date
_____________________________________________
Signature of Staff Witness Date
Consent for Mode of Contact
We are pleased to provide individuals served with several options regarding how you may be contacted regarding
services. Individuals in our services may be contacted via email, text, telephone, voicemail, and regular mail. Please let
us know how we may contact you regarding appointment reminders, healthcare communications, and any other
relevant Center information.
I consent for Texoma Community Center (TCC) staff and/or contractors to contact me for appointment reminders, to
obtain feedback regarding my experience with our services, and to provide general healthcare reminders and
information.
Please initial each of the following that apply:
____ I consent to receive text messages from TCC @ the number below.
____ I consent to receive voice messages from TCC @ the number(s) below.
____ I consent to receive e-mail from TCC at the email address below.
____ I consent to receive letters from TCC at my address of record.
Please provide us with the following information in order to contact you:
Home Phone: _________________________________ Cell Phone: ____________________________________
Email Address: _____________________________________________________________________________________
Consent for Telemedicine and Telehealth Services
To increase availability and access to Texoma Community Center Services, telehealth services are now available as
appropriate.
____ I consent to receive telehealth/telemedicine services for the purpose of assessing and treating my behavioral or
physical health needs.
• I understand that this consent remains in effect unless I request a change or revoke this consent in writing.
• I understand that record of correspondence and services provided will become a part of my medical record
kept by Texoma Community Center.
• I understand that electronic correspondence is not appropriate for emergencies or time-sensitive issues.
• I understand that I should not communicate personal or highly confidential information by email and that any
email from Center that includes PHI will be encrypted.
• I understand that TCC can not guarantee the security and privacy of electronic communications.
• I authorize the release of any relevant medical information to the provider at TCC or their agents that is
necessary to conduct these services.
______________________________________________
Signature of Individual/LAR Date
______________________________________________
Signature of Staff Witness Date
CRC-299
Created 1/25/2021
Name: MDCD #:
Page 1 of 1
CRC-25 Revised: 4/16/18 File in: Consents, R&R
Case #:
Review of Your Rights
In Local Authority Programs
Date:
My signature below shows that the following statements are true:
• I have received a verbal explanation of my rights as a person receiving services from Texoma Community
Center
• I have been given a copy of the rights booklet and its contents have been explained to me.
• I understand I have the right to participate in or refuse treatment.
• I understand my rights and know I can ask questions about my rights if I want to.
Client Signature Client Printed Name Date
Parent/Guardian/LAR Signature Parent/Guardian/LAR Printed Name and Relationship to Client Date
Staff’s Signature Who Explained Rights Staff Printed Name & Credentials/Title Date
Third-Party Witness Signature(if applicable) Third Party Witness Printed Name Date
Comments:
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Completed 8 September 2021

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