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

Primary Care

Youth Care

Adult Care

Employee Assistance Program (EAP) and Drug Free Workplace Training

Substance Use Treatment

forms

Click on desired form to print, fill out and bring with you to your appointment.

Client Registration Form

Fill out and bring to your appointment for Mental Health Services.

Diagnostic Assessment Questionnaire

Fill out and bring to your appointment for Mental Health Services.

Health History Form

Fill out and bring to your appointment for Mental Health Services.

Simple Screening Form

Fill out and bring to your appointment for Mental Health Services.

Unencrypted Email Form

Fill out and bring to your appointment for Mental Health Services.

Primary Care Intake Form.

Fill out and bring to your appointment for Physical Care Services.

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)

Insurances Accepted (Behavioral Health-Substance Use Treatment)
Must bring at time of visit

Medicaid
Medicare A & B
CareSource
Molina
Buckeye
United Health Care
UHC Community
Paramount-until 6/30/22
Anthem (We don’t accept Federal plans)
UMR

Insurances Accepted (Primary Care)
Must bring at time of visit

Aetna
Anthem
Ambetter
Buckeye Medicaid
Caresource
Cigna
Humana – some plans (no Medicare Gold Plan)
Medicaid
Medicare Part B
Molina
United Healthcare Community plan – Commercial and Medicare
Wellcare by Allwell

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 >>

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.