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Referral & Intake Screening
SELECT CLIENT SERVICE(S)
INTENSIVE IN HOME
PEER SUPPORT
DAY TREATMENT
OUTPATIENT THERAPY
CASE MANAGEMENT
MEDICATION
SUPPORTED EMPLOYMENT
B3 INDIVIDUAL SUPPORT
MULTI-SYSTEMIC THERAPY
OTHER
IF SELECTED OTHER: PLEASE LIST REQUESTED SERVICE(S)
CLIENT NAME (FIRST NAME)*
CLIENT NAME (MIDDLE NAME)*
CLIENT NAME (LAST NAME)*
CLIENT MEDICAID/INSURANCE/POLICY HOLDER* (PROVIDE NUMBER)
CLIENT DATE OF BIRTH (MM/DD/YYYY)
CLIENT AGE*
CLIENT SEXUAL ORIENTATION
*
MALE
FEMALE
NONBINARY
PREFER NOT TO SAY
OTHER
CLIENT ADDRESS*
CITY*
STATE*
ZIP*
COUNTY*
CLIENT EMAIL ADDRESS*
CLIENT HOME PHONE*
CLIENT CELL PHONE*
CLIENT’S SCHOOL NAME & ADDRESS
CLIENT’S PRIMARY CARE PHYSICIAN'S NAME, ADDRESS & PHONE
PRESENTING PROBLEMS (PLEASE BE SPECIFIC INCLUDE DIAGNOSIS IF APPLICABLE)*
OTHER SERVICES CLIENT IS CURRENTLY RECEIVING*
CLIENT'S EMERGENCY CONTACT PERSON FULL NAME
CLIENT'S EMERGENCY CONTACT PHONE
REFERRAL SOURCE NAME AND TITLE*
REFERRAL PHONE*
REFERRAL EMAIL PHONE*
LEVEL OF GUARDIANSHIP - T0 BE COMPLETED WHEN A CLIENT HAS GUARDIANSHIP OR COURT ORDERS.
ARE YOU THE LEGAL GUARDIAN OF THE CLIENT?
*
Yes
No
LEGAL GUARDIAN FULL NAME
LEGAL GUARDIAN EMAIL ADDRESS
LEGAL GUARDIAN PHONE NUMBER
LEVEL OF GUARDIANSHIP
FULL GUARDIANSHIP WITH PERSONAL AND FINANCIAL POWERS
GUARDIANSHIP OF THE PERSON
GUARDIANSHIP OF THE ESTATE (CALLED CONSERVATORSHIP IN SOME STATES)
LIMITED GUARDIANSHIP OR CONSERVATORSHIP
EMERGENCY GUARDIANSHIP, WHICH CAN LAST NO MORE THAN 90 DAYS. EMERGENCY GUARDIANSHIP CAN BE EITHER FULL OR LIMITED.
FULL GUARDIANSHIP, WHICH LASTS UNTIL THE GUARDIANSHIP IS NO LONGER NECESSARY. FULL GUARDIANSHIP GIVES THE GUARDIAN AUTHORITY TO MAKE ALL PERSONAL DECISIONS FOR THE WARD.
CURRENT MEDICATIONS (FILL IN COMPLETELY OR INDICATE NA OR UNKNOWN)
1. Name/Dosage-Frequency/Date Prescribed/Prescribed by/Efficacy-Compliance
2. Name/Dosage-Frequency/Date Prescribed/Prescribed by/Efficacy-Compliance
3. Name/Dosage-Frequency/Date Prescribed/Prescribed by/Efficacy-Compliance
4. Name/Dosage-Frequency/Date Prescribed/Prescribed by/Efficacy-Compliance
5. Name/Dosage-Frequency/Date Prescribed/Prescribed by/Efficacy-Compliance
SUBMIT DATE*
*
required
UPLOAD SUPPORTING DOCUMENTATION FOR CLIENT
Upload File
Upload supported file (Max 15MB)
SUBMIT
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