Call us today on 1-859-547-6539

Email: karant@mhankyswoh.org

Last Update: 11/11/2019

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Let's Get Signed Up!

Program Enrollment:
Are you involved with any of the following?
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What is your sex?
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What is your current marital status?
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Are you a veteran? "Veteran," meaning, did you serve in the armed forces?
Who currently lives in your residence with you? (Circle all that apply)
Do you have a physical and/or sensory disability, meaning it is not caused by a psychiatric disability?
What is the highest grade in school that you have completed?
Do you have any mental health or substance use concerns?
Have you been diagnosed with a mental health or substance use disorder?
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Indicate client's primary cause for service:
Indicate client's secondary cause for service
If Yes, what have you been told is your diagnosis? From the list, please pick all diagnosis that you have been told, or tell me wany other diagnosis that you may not be on the list:
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How would you rate your current health?
How do you feel about your life in general?
Group Schedule & Sign Up
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After completing the online enrollment questionaire, I understand I will need to complete and sign the following documents at The PIER: