Family & Children'S Services Demographic Information Page 2
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1
2If 18 Years or Older
In the past 30 days, how many times has the client been
In the past 12 months, how many times has the client been
arrested?
arrested?
In the past 30 days, how many times has the client attended self-help/support groups?
If Under 18 Years Old
In the past 90 days, how many days was the client in restrictive placement (Hospital, Treatment Facility, Etc.)?
School-Age Children
In the past 90 days of the school year, how many days was
In the past 90 days of the school year, how many days was the
the client absent from school?
client suspended from school?
Under School-Aged
In the past 90 days, how many days was the client not permitted to return to daycare?
Client Alias Name(s)
Additional Information
Current Residence
Client Living Arrangements
Nursing Home
Alone
Homeless (Living on Streets, Car, Etc.)
With Family / Relatives
Homeless – Shelter (Includes Domestic Shelter, Shelter for Homeless)
With Non-Related Persons
Institutional Setting (Correctional Facilities, Psychiatric Institutions)
Supported Housing (Housing Targeted for the Mentally Ill In the Community)
Supported Housing With Others (Housing Targeted for the Mentally Ill Maybe in Apartments)
Temporary Housing (Housing is Time Limited in Nature)
Transitional Housing (Residences for People with Mental Illness and/or Substance Addiction)
Permanent Housing (House, Duplex, Apartment, Mobile Home)
Residential Care Facility/Group Home (Group Living Situation for People with Mental Illness)
Is Client Disabled?
No
Yes (if yes, please specify what disabilities)
Military Status
Veteran
No
Active
1.
Branch of Service:
2.
3.
4.
Referral Information
Referred By:
Referral Source Name:
Emergency Contact Information
Emergency Contact Name
Emergency Contact Relationship
Living with Client?
Yes
No
Emergency Contact Address
Zip Code
City / State
County
Emergency Contact Phone
For Office Use Only:
Client Name:
Client Number:
Demographic Information UN98 09/22/14
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Form Dhcs 4514 - California Children's Services (ccs) Program Individual Provider Paneling Application For Physicians And Podiatrists - Health And Human Services Agency
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Related Categories
Parent category: Business