Clinical Forms

This page contains current forms that are commonly used by provider agencies. This is not an all-inclusive list of forms. If you cannot find a form and/or have questions, please contact the appropriate StarkMHAR Clinical Department staff member at 330-455-6644 or by their email indicated below.

I. Administrative Agency Reporting Forms

These reporting forms are required of our provider agencies on a monthly or quarterly basis, or as applicable. This list includes prevention and treatment reporting forms.

For more information on prevention reports, please contact Karen Abel Jepsen at Karen.Jepsen@StarkMHAR.org or Michele Boone at Michele.Boone@StarkMHAR.org.

For more information on treatment reports, please contact Stephanie Kutcher at Stephanie.Kutcher@StarkMHAR.org or Michele Boone at Michele.Boone@StarkMHAR.org.

 

II. Adult Care Facility (ACF) and Residential Housing Support (RHS) Forms

These forms are used in an effort to place clients in an Adult Care Facility (ACF) and for applying for Residential Housing Support (RHS). For more information, please contact Frank Aquino at Frank.Aquino@StarkMHAR.org.

 

III. Outpatient Commitment (OPC) Forms

These forms are used in an effort to coordinate treatment through Outpatient Commitment (OPC). For more information, please contact Jeannie Cool at Jeannie.Cool@StarkMHAR.org.

 

IV. Collaboration and Additional Funding Supports Forms

These forms are used when collaboration with other agencies and/or systems are needed to assist an individual.

For more information on Flexible and Consumer Recovery Support (CRS) funding, as well as the Mental Illness/Developmental Disabilities (MI/DD) collaborative, please contact Stephanie Kutcher at Stephanie.Kutcher@StarkMHAR.org.

For more information on Collaborative Care, please contact Jeannie Cool at Jeannie.Cool@StarkMHAR.org.