Intake Forms

Community Reach Center Intake Forms - Become a Patient - Woman holding pen signing agreement document

Welcome to Community Reach Center! Your first session with us is called an Intake assessment. Please click on What to Expect to understand what will take place at this meeting. We offer new admission meetings on a walk-in basis, 5 days a week from 8-2pm first come, first serve.

In preparation for your first intake meeting with us, please take a few minutes to download and complete the forms below. You may find it easier to complete these forms at home where you have all your information available. However, if you are not able to print these, forms will be available when you arrive at one of our offices. Forms are available in both English and Spanish.

Please bring an ID, insurance information, and financial information with you to walk-in intake or - if you prefer - a scheduled intake. If the client who is being assessed for services is under the age of 15 and you have either joint or primary custody, proof of legal guardianship must be presented at your intake assessment.

Please use a black ink pen to complete the form and do not fill in the date on the form until you arrive for intake.

Intake Forms—Adult English

Intake Forms—Child English

Intake Forms—Adult Spanish

Intake Forms—Child Spanish

We look forward to seeing you soon!

Postpartum Support International

Postpartum depression is more than just the “baby blues.”  It is a diagnosable illness that can interfere with a woman’s ability to care for herself and her family.

According to the Center for Disease Control, postpartum depression affects approximately 600,000 women each year. It’s important that you don’t suffer in silence. Take advantage of the resources available to you through Postpartum Support International.

Treatment plans are different for every woman, but can include increased self-care, support groups, counseling and treatment of symptoms with medication when necessary.

Talk to your doctor and visit www.postpartum.net/colorado/ for more information on postpartum depression and to see the resources available to you.

 

Para la versión en español, visite:  www.postpartum.net/ayuda/

 

Safe Drug Storage & Disposal

Safe drug disposal saves lives and protects drinking water supplies. Community Reach Center is committed to providing resources to safely dispose of unused or expired medications. Prescription drug abuse is the fastest-growing drug problem in the U.S.

NEW! Med Drop-Off Box Location:
Donald C. Ciancio Memorial Building
8989 Huron St.
Thornton, CO 80260

 

The box will be located within the building in front of the Genoa window. Medications can be dropped off Monday-Friday between the hours of 8:30 a.m. and 5 p.m. The box is closed during lunch hours from 12:30- 1 p.m.

Permanent drug collection sites can also be found at participating law enforcement agencies, pharmacies, hospitals and clinics. For more disposal options and locations, call 303-692-2903 or visit TakeMedsBack.org for other disposal locations.

Accepted medicines:
  • Over-the-counter and prescribed medicines (including prescribed controlled substances like Percocet, Oxycontin, Xanax, Ritalin, etc.)
  • Medication samples Medicated ointments
  • Vitamins
  • Pet medications
  • Unused medication patches
  • Liquid medications (small amounts in non-leaking original container)
  • Unused injection pens (EpiPens®, blood thinner injectors, insulin pens, etc.)
Cannot Be Accepted:
  • Marijuana
  • Illicit drugs (e.g. DEA Schedule I drugs like heroin, LSD, etc)
  • Needles, syringes, and other sharps
  • Chemotherapy drugs
  • Medical tools and supplies
  • Bloody or infectious waste
  • Personal care products
  • Thermometers
  • Empty containers
  • Medication wastes generated by health care facilities, including nursing homes

 

Did you know?

  • 1 in 7 Colorado high school students have taken prescription medications that were not prescribed to them.
  • 53.7% of individuals who misused prescription opioids obtained them from a friend or relative.

 

Follow these Do’s and Don’ts of medication storage and disposal to keep your family and the environment safe:

DO:

  • Store medications out of reach of children and pets. Consider a lock box to store medications safely.
  • Place syringes and other injectables in a sturdy, puncture resistant container with a screw-top lid, like a laundry detergent container.
  • Dispose of unused or expired medications safely. Use the Med Drop-Off Box at the Donald C. Ciancio Memorial Building or visit TakeMedsBack.org to find a safe disposal location near you.

 

DO NOT:

  • Flush pills or liquid medication down toilets or drains. However, used fentanyl or duragesic pain patches SHOULD be folded in half (sticky side together) and flushed down the toilet.
  • Dispose of syringes in the recycling. Instead, when container of used syringes is full, label with “Syringes – Do Not Recycle” and place in the trash.

View or download our Safe Drug Storage & Disposal flyer

Military and Veteran Families

Mission Statement/Purpose

It is our mission to assist military and veteran families in gaining access to resources and services through our center! Please read below for additional information.

Intake and Referral Process

  • Steps for Intake and Financial FAQ 
  • Veterans that have Choice can call 720-857-5976 and choose option 1.  
    Note: Choice requires that the Veteran try to schedule with an in network provider first and if they cannot get them in they will send the authorization out, bring authorization paperwork to walk-in intake or if you would like a scheduled intake.
  • Veterans that do not have Choice coverage should call Non VA Care Coordination NVCC @ 720-857-5988 and choose option 2  


Services Offered

Please review the website for specific information on our programs!  We serve clients of all ages in a variety of locations across Adams County.

Resources and Community Partners

Vet Puppy for Life provides puppies to veterans living with PTSD free of charge. Veterans must provide the puppy with a good home, keep all veterinarian appointments, and must attend all scheduled training classes.

Wounded Warrior Project is a military and veterans charity service organization empowering injured veterans and their families.

The Vet Center Program provides no-cost visits for readjustment counseling, military sexual trauma counseling, and bereavement counseling services. 

American Military Family provides emergency financial assistance, mental health intervention and therapy, and peer support to United States Military Veterans, Troops, and their families who are battling the effects of Post-Traumatic Stress and Traumatic Brain Injury in order to inspire, empower, and improve the quality of life of those Veterans who answered their nation’s call. 

Healing Warriors Program provides acupuncture, Craniosacral, and Healing Touch Therapy to service members and their family for pain, PTSD, and sleep. 

Armed Forces Vacation Club offers all eligible members of the United States Military vacations at an affordable price.

MakeTheConnection.net connects Veterans, their family members and friends, and other advocates with mental health information, local resources, and inspiring stories of recovery

For information on how to get a home loan if you are military/veteran?

https://www.benefits.va.gov/homeloans/purchaseco_certificate.asp

https://www.benefits.va.gov/homeloans/

    Suicide Awareness & Prevention

    People discussing suicide awarenessIn the pursuit of safety for our clients and staff, Community Reach Center is committed to promoting suicide awareness and prevention in our community. As a proud partner of the Zero Suicide movement, Community Reach Center was the first to host the two-day Zero Suicide Academy in Colorado. We know that having the conversation with loved ones about suicide risk is difficult. However, if someone you know is exhibiting behaviors that lead you to wonder if they are contemplating suicide, it’s important to talk to them. You may need to muster the courage to ask the question directly and nonjudgmentally: “Are you thinking of killing yourself?” If they answer “yes”, follow up immediately by asking if they have a plan as to how and when they intend to do it.  If they answer “yes”, that is a clear indicator that they are at imminent risk and need to access crisis services immediately. Take the person to one of the Colorado Crisis Services walk-in centers or a hospital emergency room immediately, or call 911.

    Although it may feel awkward, asking the question is a powerful way to acknowledge his or her pain and suffering, which can be a life-saving source of hope and support to them. Please see below for information on suicide warning signs and risk factors, followed by resources and tools that are available for consumers and their support systems. 

    Suicide Warning Signs

    While a person may attempt or complete suicide without having exhibited any warning signs, in many cases there are indicators that they are contemplating taking action. In general, significant changes in behavior or new behaviors, especially related to painful life events, may be cause for concern and heightened suicide awareness.  

    Specific suicide warning signs include:

    • Talk of self-injury or suicide
    • Searching for the means to attempt suicide (information, weapons, etc.)
    • Expressing feelings of hopelessness or of being a burden to others
    • Talk of unbearable pain or feeling trapped
    • Withdrawing from loved ones
    • Increased use of drugs or alcohol
    • Sleeping too little or too much
    • Selling or giving away important possessions
    • Irritation or aggressive behavior
    • Connecting with people to “say goodbye” (even if that sentiment is not expressed)

    Suicide Risk Factors

    Some people are at a higher risk of attempting or completing suicide based on certain conditions in their life. These factors include their health, living environment and behavioral history. Being familiar with suicide risk factors is important, because they can help you determine when to practice a greater degree of suicide awareness around someone you are concerned about.

    Specific suicide risk factors include:

    • Mental health conditions such as depression, bipolar disorder, anxiety disorders, schizophrenia, mood disorder, aggression and difficulty establishing or maintaining relationships
    • Traumatic brain injury
    • Chronic and/or painful health issues
    • Access to the means of attempting or completing suicide such as weapons, drugs, etc.
    • Previous suicide attempts
    • Current or past abuse, bullying or harassment
    • Frequent or ongoing unemployment or financial troubles
    • Stressful life events such as the death of a loved one, divorce or loss of a significant relationship, foreclosure, etc.
    • Suicide of a friend or family member

    General resources and information:

    Resources for youth:

    Intake Forms Child — Spanish

    Community Reach Center Intake Forms - Become a Patient - Woman holding pen signing agreement document

    Bienvenido al llegar al centro de la comunidad! Su primera sesión con nosotros se llama una reunión "Nueva Entrada". Por favor, haga clic en  ¿Qué esperar  de entender lo que se llevará a cabo en esta reunión. Ofrecemos nuevas reuniones de admisión en base a ras de suelo, 5 días a la semana a partir de 8-2pm primer llegado, primer servido.

    En preparación para su primera reunión de admisión con nosotros, por favor, tómese unos minutos para descargar y completar los formularios a continuación. Puede que le resulte más fácil completar estas formas en el hogar donde se tiene toda la información disponible. Sin embargo, si usted no es capaz de imprimir estos, formularios estarán disponibles cuando llegue a una de nuestras oficinas. La mayoría de los formularios están disponibles en Inglés y Español.

    Por favor use una  tinta de color negro  pluma para completar el formulario y no llene la fecha en el formulario hasta que llegue a la ingesta.

     

    Intake Fax Coversheet View PDF
    FORMULARIO DE ADMISIÓN al Community Reach Center
    información demográfica
    View PDF
    FORMULARIO FINANCIERO DEL CONSUMIDOR 
    F página rimero completa totalmente sobre su información de seguro. 
    Señal de que podemos divulgar información a su seguro y que se autoriza el pago. Sírvanse también proporcionar  una copia de su tarjeta de identificación y el seguro (frente y parte posterior). Lea cuidadosamente la segunda página y conservar para sus registros
    View PDF
    Declaración de ingresos
    Pedimos sus ingresos familiares para determinar la cantidad que pagaría en una escala de precios, si usted no tiene seguro o si alguna vez perdido su seguro. Pedimos a todos que completar esto.
    View PDF
    Forma de Admision para servicos mentales 
    Describe el motivo de su visita
    View PDF
    Historia Médica
    información médica incluyendo sus medicamentos actuales y proveedor médico actual.
    View PDF
    We look forward to seeing you soon!

    Intake Forms Adult—Spanish

    Community Reach Center Intake Forms - Become a Patient - Woman holding pen signing agreement document

    Bienvenido al llegar al centro de la comunidad! Su primera sesión con nosotros se llama una reunión "Nueva Entrada". Por favor, haga clic en  ¿Qué esperar  de entender lo que se llevará a cabo en esta reunión. Ofrecemos nuevas reuniones de admisión en base a ras de suelo, 5 días a la semana a partir de 8-2pm primer llegado, primer servido.

    En preparación para su primera reunión de admisión con nosotros, por favor, tómese unos minutos para descargar y completar los formularios a continuación. Puede que le resulte más fácil completar estas formas en el hogar donde se tiene toda la información disponible. Sin embargo, si usted no es capaz de imprimir estos, formularios estarán disponibles cuando llegue a una de nuestras oficinas. La mayoría de los formularios están disponibles en Inglés y Español. Sírvanse también proporcionar una copia del DNI y tarjeta de seguro (frente y parte posterior de un seguro privado).

    Por favor use una  tinta de color negro  pluma para completar el formulario y no llene la fecha en el formulario hasta que llegue a la ingesta.

     

    Intake Fax Coversheet View PDF
    FORMULARIO DE ADMISIÓN al Community Reach Center
    información demográfica
    View PDF
    FORMULARIO FINANCIERO DEL CONSUMIDOR 
    F página rimero completa totalmente sobre su información de seguro. 
    Señal de que podemos divulgar información a su seguro y que se autoriza el pago. Sírvanse también proporcionar  una copia de su tarjeta de identificación y el seguro (frente y parte posterior). Lea cuidadosamente la segunda página y conservar para sus registros
    View PDF
    Declaración de ingresos
    Pedimos sus ingresos familiares para determinar la cantidad que pagaría en una escala de precios, si usted no tiene seguro o si alguna vez perdido su seguro. Pedimos a todos que completar esto.
    View PDF
    Preguntas sobre el uso de drogas y alcohol
    de detección de abuso de sustancias
    View PDF
    Forma de Admision para servicos mentales 
    Describe el motivo de su visita
    View PDF
    Historia Médica
    información médica incluyendo sus medicamentos actuales y proveedor médico actual.
    View PDF
    ¡Esperamos verte pronto!

    Intake Forms Child — English

    Community Reach Center Intake Forms - Become a Patient - Woman holding pen signing agreement document

    Welcome to Community Reach Center! Your first session with us is called a "New Admission" meeting. Please click on What to Expect to understand what will take place at this meeting. We offer new admission meetings on a walk-in basis, 5 days a week from 8-2pm first come, first serve.

    In preparation for your first intake meeting with us, please take a few minutes to download and complete the forms below. You may find it easier to complete these forms at home where you have all your information available. However, if you are not able to print these, forms will be available when you arrive at one of our offices. Most forms are available in both English and Spanish. Please also provide a copy of your ID and insurance card (front and back for private insurance).

    Please use a black ink pen to complete the form and do not fill in the date on the form until you arrive for intake.

     

    Intake Fax Coversheet View PDF
    Admission Form 
    Demographic information
    View PDF
    Consumer Financial Form 
    First page complete fully about your insurance information. 
    Sign that we can release information to your insurance and you are authorizing payment. Please also provide a copy of your ID and insurance card (front and back). Carefully read the second page and keep for your records
    View PDF
    Proof of Income Form 
    We ask for your household income to determine the amount you would pay on a sliding scale fee, if you do not have insurance or if you ever lost your insurance. We ask everyone to complete this.
    View PDF
    Brief Triage Form 
    Describe the reason for your visit
    View PDF
    Medical History Form 
    Medical information including your current medications and current medical provider.
    View PDF
    We look forward to seeing you soon!

    Intake Forms Adult — English

    Community Reach Center Intake Forms - Become a Patient - Woman holding pen signing agreement document

    Welcome to Community Reach Center! Your first session with us is called a "New Admission" meeting. Please click on What to Expect to understand what will take place at this meeting. We offer new admission meetings on a walk-in basis, 5 days a week from 8-2pm first come, first serve.

    In preparation for your first intake meeting with us, please take a few minutes to download and complete the forms below. You may find it easier to complete these forms at home where you have all your information available. However, if you are not able to print these, forms will be available when you arrive at one of our offices. Most forms are available in both English and Spanish. Please also provide a copy of your ID and insurance card (front and back for private insurance).

    Please use a black ink pen to complete the form and do not fill in the date on the form until you arrive for intake.

     

    Intake Fax Coversheet View PDF
    Admission Form 
    Demographic information
    View PDF
    Consumer Financial Form 
    First page complete fully about your insurance information.
    Sign that we can release information to your insurance and you are authorizing payment. Please also provide a copy of your ID and insurance card (front and back). Carefully read the second page and keep for your records
    View PDF
    Proof of Income Form 
    We ask for your household income to determine the amount you would pay on a sliding scale fee, if you do not have insurance or if you ever lost your insurance. We ask everyone to complete this.
    View PDF
    Substance Use Screening 
    Substance abuse screening
    View PDF
    Brief Triage Form 
    Describe the reason for your visit
    View PDF
    Medical History Form 
    Medical information including your current medications and current medical provider.
    View PDF
    We look forward to seeing you soon!