Forms | South Community

Our agency buildings will not be open on Thursday 2/3 or Friday 2/4. All scheduled appointments will be switched to telehealth. Clients will be notified via phone.

Forms

Youth Care

Adult Care

Employee Assistance Program (EAP)

Substance Use Treatment

forms

Welcome!
We are here to help with Mental Health, and Substance Use Care.

Please bring these items when you come in:
– Proof of Income
– Proof of Residence
– Proof of Insurance
– Proof of Custody (if applicable)

First visit may take approximately 3-4 hours to ensure we serve you well.
Walk-in, 8 AM to 2 PM, Monday through Friday

Using library below, print out intake forms and bring with you when you come in.

Mental Health Services

Client Registration Form

Diagnostic Assessment Questionnaire

Health History Form

Modified Simple Screening Instrument and Tool

Insurances Accepted: Must bring at time of visit

Anthem, not federal
Buckeye
Humana
United Health Care

UMR
Marketplace: Buckeye, Caresource, Humana

Medicaid Accepted: Must bring at time of visit

Traditonal Medicaid (Part B)
Aetna Better Health (Ohio Rise)
Anthem BCBS Medicaid
Amerihealth Caritas Ohio Medicaid/li>
Buckeye
Buckeye MyCare Medicaid Only

Caresource
Humana Healthy Horizons
Molina
Molina Mycare Medicaid Only
United Healthcare Community Plan

Physician Referrals

Authorization for Release of Information

Meds Only Intake Referral

Click on desired file to print and keep for your records.

Client Rights Brochure

Notice of Privacy Practices

Grievance Procedures

Request for PHI (Protected Health Information)

We are committed to providing the best care to the persons we serve. Please share suggestions that would improve your experience working with South Community.

To Whom It May Concern:
I am a parent of a child with special needs. We have been involved with South Community for many years. It is a partnership that I have come to rely on as an integral part of my son’s support system.

The summer program that South Community has in place is an awesome program that provides a wonderful opportunity for many kids at risk, who otherwise would be left out of a truly adventurous experience. READ MORE >>

I honestly do not know what I would have done without South Community. It has helped me so much in rebuilding my life. I went from living at home with my mother for financial reasons, and also severe depression, to having a place of my own and a job!

Thanks to South Community, I was able to get the therapy I needed. I was also able to obtain a caseworker, Lynn Wynstrep. Lynn helped me get my life back in order. READ MORE >>

To Staff of South Community:
Thank you all for a wonderful training year. You guys were a great supportive staff to work with. I felt like I was part of the team here, and I appreciate everyone for helping me with anything I needed throughout the year.

I know that many agencies talk about having a recovery focus, but the staff here truly implements it. I noticed it and my clients noticed it. From the front service desk to the providers in the back, there is an emphasis on client care. READ MORE >>