Oakland Community Health Network

Recipient Rights Training Test v2

Please fill out the form below. Fields marked with an asterisk * are required.

First Name: *

Last Name: *

Your Email Address: *

Repeat Email Address: *

Your Home Street Address: *

Apartment or Unit #:

Your City: *

Your 5-Digit Zip Code: *

Your Date of Birth: * (MO/DAY/YEAR)

Your Driver's License Or State Issued ID# *

Your Core Provider: *
(or if independent their core provider)

Your Agency / Location:*
(or "Employer of Record" if independent)

By checking this box, I agree to adhere to The Michigan Mental Health Code and the Due Process Regulations. Violations may be subject to disciplinary action.