How do I submit the Adult SPOA Application?

Email, mail, or fax it to the SPOA Unit – Adult Mental Health Services at the address, email, or fax number listed on the form. Send single-sided copies without staples or paperclips.

What supporting documents may be required?

Requirements depend on the service requested. The form lists an eligibility determination, completed application, psychosocial assessment with an ICD-10 diagnosis, and physician’s authorization for applicable services.

Orange County, NY · Orange County

No notary required

Adult Single Point of Access Application

Adults and referring providers use this application to request Orange County mental health care management, ACT services, or residential services through the Single Point of Access.

At a glance

Issued by: City of Orange County · Orange County, Orange County, New York
Notarization: Not required: file this form without a notary.
Official source: orangecountyny.gov
Blank form: Download the PDF
Catalogued: Oct 5, 2026
Machine-readable: JSON record · about the forms index

What this form is

This application requests adult Single Point of Access services from the Orange County Department of Mental Health, including care management, Assertive Community Treatment, and residential options. It asks about the applicant’s eligibility, personal and clinical history, requested services, and referral source. Required supporting documents depend on the service requested; the application also includes health-information release and PSYCKES consent forms.

Who needs it

An adult applicant or referring provider seeking Orange County SPOA care management, ACT, or residential services should complete this application.

How to submit it

Email, mail, or fax the application to the SPOA Unit – Adult Mental Health Services, Orange County Department of Mental Health, at 30 Harriman Drive, Goshen, NY 10924. The form lists [email protected] and fax (845) 360-9074; send single-sided copies without staples or paperclips.

About notarization

This application is signed without a notary; the included health-information release and PSYCKES consent forms call for signatures, and the form does not require notarization.

How to submit this form

1
Download the Application
Download the Adult Single Point of Access Application PDF.
2
Complete the Application
Fill in applicant, eligibility, clinical, referral, and requested-service information.
3
Gather Supporting Documents
Check the form’s documentation table for items required for the requested service.
4
Send It to the SPOA Unit
Email, mail, or fax single-sided copies to the SPOA Unit using the contact details on the form.

Frequently asked questions

Do I need a notary for the Adult SPOA Application?: No. This application is signed without a notary. The included health-information release and PSYCKES consent forms call for signatures, not notarization.
How do I submit the Adult SPOA Application?: Email, mail, or fax it to the SPOA Unit – Adult Mental Health Services at the address, email, or fax number listed on the form. Send single-sided copies without staples or paperclips.
What supporting documents may be required?: Requirements depend on the service requested. The form lists an eligibility determination, completed application, psychosocial assessment with an ICD-10 diagnosis, and physician’s authorization for applicable services.
What services can I request with this application?: The application includes requests for care management, Assertive Community Treatment, and residential services, with housing options described in the form.

Need something notarized?

This Adult Single Point of Access Application doesn’t need a notary, but if you have another Orange County form that does, a commissioned online notary can help.