Sam-Inc | Request for Services

Location of person completing this form?

Outside SAM Office SAM Office

Name of person who will receive services

First and Last Name

Date of birth of person who will receive services

DOB

Parent or Guardian if person is under age 14

Parent/Guardian Name

Thank you, , for reaching out to us.

Please answer the following questions to help us to determine the best method of serving you.

Do you have a permanent address?

Yes No

Please enter your address.

Address (include City State Zip)

Where can we find you?

Location

Do you have a phone number?

Yes No

Please enter your phone number.

Enter Phone Number

Is there another number you can be reached at?

Yes No

Please enter the phone number where you can be reached at.

Whose phone is this and what is their relationship to you?

Is it ok to leave a message at this number?

Yes

Do you have access to a smart phone with data or a computer with internet?

Yes No

We have determined the best way to serve you is face to face.

Please visit our office at 19 N 6th Street Reading, Pa or call us at 610-236-0530 to schedule an appointment.

Is this your phone?

Yes No

Is it ok to leave a message at this number?

Yes No

Can you receive text messages at this number?

Yes No

Do you have an email address?

Yes No

Please enter your email address.

Email Address

We have determined the best way to serve you is by phone.

Please continue.

Do you feel like you are at risk of hurting yourself or someone else?

Yes No

Thank your for your time!

A crisis worker will be in contact with you shortly. You can also contact Crisis at 610-236-0530.

Thank your for your time!

Please call 911. You can also contact your local Crisis center at

We will reach out to you to follow up and offer additional services.

Thank your for your time!

Please call 911. You can also contact your local Crisis center at

We will reach out to you to follow up and offer additional services.

Health Questions

Please answer the following health questions:

Have you had any of the following medical problems in the last 14 days?

Temperature over 100 degrees
Chills
Cough
Shortness of breath
Difficulty breathing
Fatigue
Muscle/Body Aches

Headache
New loss of taste or smell
Congestion or runny nose
Sore throat
Nausea or Vomiting
Diarrhea

Yes No

Have you had contact with anyone who has known or possible exposure to the coronavirus (COVID-19) or other communicable condition in the last 14 days?

Yes No

Are you on home quarantine or isolation due to possible contact with someone with possible or confirmed coronavirus (COVID-19)?

Yes No

Have you received a positive COVID-19 test in the last 30 days or have pending results from a recent COVID test?

Yes No

Thank your for your time!

Someone will reach out to you before the end of the business day by phone.

Thank-you!

Now that we have determined the best method of reaching you, let's determine why you are reaching out to SAM, Inc.

Were you told to come to SAM by another provider?

Yes No

Have you received Mental Health Services in the past at SAM?

Yes No

Are you currently involved with other Social Services Programs?

Yes No

Have you been evaluated for or admitted to inpatient for Mental Health reasons in the last 90 days?

Yes No

Do you need special assistance/accommodations when receiving services?

Yes No

Which special accommodations do you require?

Language Services

Hearing Services

Handicap Accessibilty

How many times in the last 30 days have you used alcohol and/or drugs not prescribed to you?

I do not use alcohol or non-prescribed drugs

1-5 times

6-10 times

10 or more times

Do you currently have any insurance coverage?

Yes No

What type/s of insurance do you have?

Private Insurance

Medical Assistance

Medicare
Medicaid

PerForm Care
Behavioral Health

Please call True North at 717-485-3264. Thank-you!

Please list any other services you are seeking:

Other Services

If you need Information about a service offered by an agency below please click on the (?) to find the agency phone number.

Children and Youth Services: For reporting suspicions of Child/Abuse Neglect contact ChildLine at 1-800-932-0313. To inquire about programs contact 570-724-5766 during normal business hours 8am-4pm Monday-Friday.

Aging Services: To report suspected elder abuse or to access services though Aging please call 1-800-982-4346

County Board of Assistance: Need help with cash assistance programs, State Blind Pension, Supplemental Security Incomes (SSI), Food Stamps. Medical Assistance including Healthy Beginnings and Healthy Horizons, nursing home care, employment, and training programs providing linkages to community agencies. Call: 570-724-4051

Transportation: Need help with transportation to/from medical appointments? Contact 1-800-242-3484 or Mansfield: 570-659-5330, Athens: 570-888-7330 #221

Vocational Rehabilitation Services: Provides vocational rehabilitation services to help persons with disabilities prepare for, obtain, or maintain employment. Call: 570-327-3600

Thank you for your time, !

Please click the SUBMIT button below to send us your information.

Request for Services

Select County:

Location of person completing this form?

Name of person who will receive services

Date of birth of person who will receive services

Parent or Guardian if person is under age 14

Thank you, , for reaching out to us.

Do you have a permanent address?

Please enter your address.

Where can we find you?

Do you have a phone number?

Please enter your phone number.

Is there another number you can be reached at?

Please enter the phone number where you can be reached at.

Whose phone is this and what is their relationship to you?

Is it ok to leave a message at this number?

Do you have access to a smart phone with data or a computer with internet?

We have determined the best way to serve you is face to face.

Is this your phone?

Is it ok to leave a message at this number?

Can you receive text messages at this number?

Do you have an email address?

Please enter your email address.

We have determined the best way to serve you is by phone.

Do you feel like you are at risk of hurting yourself or someone else?

Thank your for your time!

Thank your for your time!

Thank your for your time!

Health Questions

Have you had any of the following medical problems in the last 14 days?

Have you had contact with anyone who has known or possible exposure to the coronavirus (COVID-19) or other communicable condition in the last 14 days?

Are you on home quarantine or isolation due to possible contact with someone with possible or confirmed coronavirus (COVID-19)?

Have you received a positive COVID-19 test in the last 30 days or have pending results from a recent COVID test?

Thank your for your time!

Thank-you!

Were you told to come to SAM by another provider?

Who referred you to SAM?

Have you received Mental Health Services in the past at SAM?

Are you currently involved with other Social Services Programs?

Have you been evaluated for or admitted to inpatient for Mental Health reasons in the last 90 days?

Do you need special assistance/accommodations when receiving services?

Which special accommodations do you require?

How many times in the last 30 days have you used alcohol and/or drugs not prescribed to you?

Do you currently have any insurance coverage?

What type/s of insurance do you have?

What service(s) are you seeking? Mark all that apply.

Please list any other services you are seeking:

Thank you for your time, !