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Patient intake form
This form must be filled out in entirety in order to allow for medical necessity and authorization for services. Please include most current Psychosocial and any Custody Orders if applicable with referral.
Client Name
Date of birth
Address
Address
City
Client Phone
SS No
Medicaid Number
Mental Health Diagnosis
Primary Health Diagnosis
Clinical Criteria Impacting Diagnosis ( Demonstrates impaired role functioning for at least 2 years as evidenced by at least three of the following , if not at least 2 years, must be a new onset diagnosis)
Choose one or more options
Marked inability to establish or maintain independent competitive employment
Marked inability to perform instrumental activities of daily living
Marked inability to establish or maintain a personal support system
Marked or frequent deficiencies of concentration, persistence or pace
Marked inability to perform or maintain self-care
Marked deficiencies in self-direction
Social Elements Impacting Diagnosis
Choose one or more options
None
Access to Healthcare
Education
Financial
Legal System/Crime
Primary Support
Housing Problems
Occupational
Other Pschosocial/Enviro
Social Environment
Homelessness
Unknown
Individual experiences at least three of the following
Choose one or more options
Inability to maintain independent employment
Social behavior that results in intervention by mental health system
Inability to procure financial assistance due to cognitive disorganization
Severe inability to establish or maintain social supports
Need or assistance with basic living skills
Reason for Referral
- Select -
Recent Psychiatric Hospitalization
Medication Non -Compliance and Symptom Fluctuation
Justice System Involvement
Frequent Use of Crisis Services
Chronic Mental illness with Poor Coping Skills
Functional Impairment in Daily Living
Housing Instability in Daily Living
Frequent Job Loss or Employment Instability
Educational Disruption Due to Mental Health
Substance Use Relapse Risk
Lack of family or community Support
Transition from Inpatient to community
History of Self-Harm or High Risk Behaviors
Poor Insight into illness
Loss of Benefits or Difficulty Navigating Systems
Enter Reason
Current Medication
Is the individual Med Compliant?
Yes
No
Unknown
Presenting Symptoms ( Please include history of SI and HI )
Reason For Referral
Self - Care Skills
- Select -
Personal Hygiene
Grooming
Nutrition
Dietary Planning
Self Administration of Medicine
Appearance
Social Skills
- Select -
Community Integration Activities
Developing Natural Supports
Developing Linkages with and Supporting the Individuals Participation in Community Activities
Age-appropriate Boundaries
Interactive Skills with Authority Figures
Anger Management
Conflict Resolution
Interactive Skills with Peers
Independent living skills
- Select -
Skills necessary for Housing Stability
Coummunity Awareness
Mobility and Transportation Skills
Money Management
Accessing Available Entitlements and Resources
Supporting the Individual to obtain and Retain employment
Health Promotion and Traning
Time Management
Individual Wellness Self - management and Recovery
Provide a brief description of how PRP services will benefit client
Most Recent Psychiatric Hospitalization ( Where and When, if any)
Reffering Professional's Name
Psychiatrist Name
NPI Number
Date
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