Family and Support System Information

 

ATTENTION - PLEASE READ


StarCare Specialty Health System does not prescribe stimulants (including but not limited to Adderall, Vyvanse, Ritalin) or benzodiazepines (including but not limited to Xanax, Klonopin, Valium, Ativan).


Medication management resources outside of StarCare can be found by calling 211 Texas (dial 2-1-1) or visit their website at https://www.211texas.org.

 

If you are experiencing a mental health crisis, call 806-740-1414 or 800-687-7581.

 

 

StarCare Specialty Health System takes all necessary steps to ensure Health Insurance Portability and Accountability Act (HIPAA) compliance. For more information, click the "Privacy Notice" link at the bottom of this form.

 

 

Instructions for Completing Intake Forms

Complete the following information for the person seeking services with StarCare Specialty Health System. If a question is not applicable, enter “N/A” in the space provided.


Completing this information ahead of time will shorten the time needed to complete your intake. Upon completion of the intake process, if eligible, you will be authorized for services based on your need. You will be assigned a case manager to assist you with accessing needed resources and services.

 

Before beginning this form, it is recommended you gather and have the following information available, if applicable:


  • Legal guardian/representative address
  • Legal guardian/representative phone number
 

 
 
 
 
 
 
mm/dd/yyyy
 

 
 
 
Phone
 
 
 
 
 
 
 
 

 
 

 

Select the guardian's primary phone number type and enter the phone number below. A cell phone number is required to receive automated appointment reminders.

 
Phone
 

 

Select the guardian's alternate phone number type and enter the phone number below. A cell phone number is required to receive automated appointment reminders.

 
Phone
 

 

By typing my full name below, I certify the information provided is true and complete to the best of my knowledge. I understand typing my name is a legal signature and is considered the same as my handwritten signature.

 
 
 
mm/dd/yyyy