Community Care Behavioral Health Pre-Intake Form printable pdf download

COMMUNITY CARE BEHAVIORAL HEALTH

PRE-INTAKE SCREENING FORM

(To accompany Intake Form)

Client’s Name: __________________________________________________________________Date: ______________

Client Address _____________________________________________________ Cell #: _________________________

City: ___________________________State:_______ Zip Code: ______________House #: ________________________

Medicaid #: ____________________________

DOB_____________ Age: _________S.S.#____________________

Referral Source/ Title:_____________________________________________________Tele.:_____________________

Agency: _________________________________________________________________Fax: _____________________

Address:__________________________________________________________________________________________

Residence Contact Person(s): ________________________________Tele:_______________ Cell #: ______________

Presenting Problem/Reason for Referral: ______________________________________________________________

_________________________________________________________________________________________________

__________________________________________________________________________________________________

___________________________________________________________________________________________________

_________________________________________________________________________________________________

Date of Most Recent Psychiatric Hospitalization: ____________Name of Hosp:__________________________________

Provisional Diagnosis: (See Intake for Final Diagnosis)

AXIS I:___________________________________________________________________________________________

AXIS II: __________________________________________________________________________________________

AXIS III: _________________________________________________________________________________________

Primary Physician: _____________________________________________Tele: ________________________________

Primary Psychiatrist: ___________________________________________ Tele: ________________________________

Transfer to program psychiatrist: Y ___ N ___ (If yes, please √ if former psychiatrist sent clinic letter w/date_________)

Pharmacy:____________________________________________________ Tele: ________________________________

Mental Health providers currently utilized, please

Case Manager __ Social Worker __Psychiatrist__Therapist __Other _

√

Agency: ______________________________Contact: ____________________________Tele:_____________________

Other Services providers currently utilized and types of services: _____________________________________________

Agency: ______________________________Contact: ____________________________Tele:_____________________

Medicaid status pending approval by: Med. Needy/ NJ Care Medicare #: ____________________Other: ____________

Intake Appointment Date: __________ Time: _____Intake Completed On: ___________ Scheduled start date: _________

Probat. Per.: ____________ Completed: Y N Reason: ____________________ Last Day Attended: ______________

Program Schedule: ______________________________________________ Program Criteria Met: Yes No Unsure

Intake Worker’s Signature: _____________________________Title: ___________________ Date: _____________

Community Care Behavioral Health Pre-Intake Form