GetHelpNow - Agency Update/Request Form

Below is a form to request to have an agency added to the GetHelpNow Montgomery County Mobile app. Completing the form does not guarantee the agency will be added to the app. The request will be reviewed by our Treatment Team to determine how it best fits into the app.

There is currently a pending update for this record. Once it has been reviewed, then you can come back to this page and make another update.

Agency Name:

Provider Types:
Alcohol/Drug Mental Health

OhioMHAS Certified:
Yes Please upload a copy of your OhioMHAS Certificate (PDF only):

Faith Based:
Yes

Payer Types:
Medicaid Medicare Sliding Fee Scale Other (Insurance, VA Benefits) Self Pay

Website:

Contact Information:

Address 1:

Address 2:

City:

State:

Zip Code:

*This validates that address with Google Maps so it will display properly in the app.
Phone:

Service Identifiers: Treatment Providers should only select those services listed on their agency OhioMHAS Certification or Licensure certificate

Service Name	Adult	Adolescent	Child
Alcohol and Drug Assessment	Adult	Adolescent	Child
Mental Health Assessment	Adult	Adolescent	Child
Case Management	Adult	Adolescent	Child
Outpatient / Counseling	Adult	Adolescent	Child
Crisis Intervention	Adult	Adolescent	Child
Detoxification	Adult	Adolescent	Child
Forensic Evaluation	Adult	Adolescent	Child
Intensive Outpatient	Adult	Adolescent	Child
Suboxone Treatment	Adult	Adolescent	Child
Vivitrol Treatment	Adult	Adolescent	Child
Methadone Treatment	Adult	Adolescent	Child
Naloxone / Narcan	Adult	Adolescent	Child
Medication Assisted Treatment (MAT)	Adult	Adolescent	Child
Psychotropic Medication	Adult	Adolescent	Child
Day Treatment	Adult	Adolescent	Child
Peer Support	Adult	Adolescent	Child
Referral & General Information	Adult	Adolescent	Child
Residential Treatment	Adult	Adolescent	Child
Foster Care/Adoption	Adult	Adolescent	Child
Social/Recreational Services	Adult	Adolescent	Child
*Hotline	Adult	Adolescent	Child
SOAR	Adult	Adolescent	Child
Medication Drop Box Locations	Adult	Adolescent	Child
Pregnant Women	Adult	Adolescent	Child
Food Assistance	Adult	Adolescent	Child
Suicide Intervention	Adult	Adolescent	Child
Domestic Violence	Adult	Adolescent	Child
Victim or Witnesses of Felony Offense	Adult	Adolescent	Child
Transportation	Adult	Adolescent	Child
Recovery Housing	Adult	Adolescent	Child
Mental Health Housing	Adult	Adolescent	Child
Homeless Resources	Adult	Adolescent	Child
People Seeking Jobs	Adult	Adolescent	Child
Adult Basic Education (ABE)	Adult	Adolescent	Child
General Equivalency Diploma (GED)	Adult	Adolescent	Child
Continuing Education (CE)	Adult	Adolescent	Child
English for Speakers of Other Languages (ESOL)	Adult	Adolescent	Child
Senior Adult Services	Adult	Adolescent	Child
Special Services	Adult	Adolescent	Child
*National Hotline/Treatment Finder	Adult	Adolescent	Child
LGBTQ2+	Adult	Adolescent	Child
Warmline	Adult	Adolescent	Child
Here to Assist Local Workforce	Adult	Adolescent	Child
Supportive Workforce Recovery Workplaces	Adult	Adolescent	Child

Person completing this form:

E-mail address for person completing this form:

GetHelpNow Montgomery County - Agency Update/Request Form

Contact Information:

Service Identifiers: Treatment Providers should only select those services listed on their agency OhioMHAS Certification or Licensure certificate