| CONSUMER INFORMATION |
|
| *Consumer Name: |
|
| Date of Birth: |
|
| Age: |
|
| SSN: |
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| Gender: |
|
| Race: |
|
| Consumer Address: |
|
| Consumer City: |
|
| Consumer State: |
|
| Parent/Guardian
Name: |
|
| Area
Code/Home
Phone: |
(xxx)xxx-xxxx |
| Area Code/Cell
Phone: |
(xxx)xxx-xxxx |
| Area Code/Work
Number: |
(xxx)xxx-xxxx |
| OTHER SERVICE PROVIDERS |
|
Is child receiving
any other
Mental Health services? |
If yes, answer next two questions. |
What is the location
of the
Mental Health Service? |
|
What Type
Mental
Health Service? |
|
| CLINICAL ELIGIBILITY |
|
Has the child
sought treatment
at a lower level of care? |
(e.g. Community Support, Individual, Consumer
Support Team, Individual and Family Counseling) |
Does the child
have a known
Serious Emotional Disturbance? |
|
Does the child
have a known
Substance Abuse Issue(s)? |
|
Does the child
have a known
Co-occurring Mental Health Illness
and Substance Abuse Issue(s)? |
|
Does the Child
have a known
or suspected Mental Illness or
Substance Abuse (ASAM II.5)
diagnosis? |
|
Are child and/or
family issues
unmanageable in traditional
outpatient treatment and require
intensive, coordinated clinical and
supportive intervention? |
|
Is the child at
immediate risk of
out-of-home placement or is
currently in out-of-home placement
and re-unification is imminent? |
|
Is the child currently
experiencing
a psychotic condition requiring a
more restrictive level of care? |
If yes, please refer consumer to psychiatric
hospital or crisis stabilization unit
|
| ADMISSION STATUS |
|
| Voluntary? |
|
| Court Mandated? |
|
| Agency Referral |
If so, add Agency name below.
|
| Agency Name |
|
Name of Person
Making Referral |
|
Title of Person
Making
Referral |
|
Area
Code/Phone of
Person Making
Referral |
(xxx)xxx-xxxx |
| INSURANCE |
|
Does the child
have Medicaid or
Georgia Peachcare For Kids? |
|
Medicaid or Georgia
Peachcare
Insurance number |
|
| PRESENTING PROBLEM |
|
Chief
Complaint (includes
if related to Family, Environment,
Peer Interactions, School
Environment, Skill and/or
Developmental Deficiencies and
Current Stressor)
(max. chars: 250) |
|
Comment
(max. chars: 250) |
|
| FACP Sales Person |
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