COMMUNITY CARE BEHAVIORAL HEALTH

131 ETHEL RD W –SUITE 3A

PISCATWAY, NJ 08854

TEL. 732-572-4666 FAX 732-572-9304

Client’s Name: Click here to enter text. Date: Click here to enter date.

Client Address: Click here to enter text.

City: Click here to enter text. State: text. Zip Code: Click here to enter text. Tel: Click here to enter text.

DOB: Click here to enter text. Age: text. S.S. #: Click here to enter text. Medicaid #: Click here to enter text. Approved? Y☐ N☐

Referral Source/ Title: Click here to enter text. Tel: Click here to enter text.

Agency: Click here to enter text. Fax: Click here to enter text.

Residence Contact Person(s): Click here to enter text. Tel: Click here to enter text.

Presenting Problem/Reason for Referral: Click here to enter text.

Presenting Symptoms: Click here to enter text. Hx Suicide Attempts: Y ☐ N ☐ Dates: Enter a date.

Other Partial Care Programs Attended: Click here to enter text.

Attendance (check): Good ☐ Fair ☐ Poor ☐ Participation (check): Good ☐ Fair ☐ Poor ☐

Reason for Leaving: Click here to enter text. Dates: Click here to enter a date. to Click here to enter a date.

Hx Alcohol/Drug Abuse: Y☐ N☐ Drug of Choice: Click here to enter text.

Date Last Used: Click here to enter a date.

Date Span of Most Recent Psychiatric Hospitalization: Click here to enter a date. to Click here to enter a date. Name of Hospital: Click here to enter text.

Provisional Diagnoses: Click here to enter text. Provided By: Click here to enter text.

Primary Physician: Click here to enter text. Tel: Click here to enter text.

Primary Psychiatrist: Click here to enter text. Tel: Click here to enter text.

Transfer to program psychiatrist: Y☐ N ☐ (If yes, please √ if former psychiatrist sent clinic letter w/date Click here to enter a date.)

Pharmacy: Click here to enter text. Tel: Click here to enter text.

Mental Health providers currently utilized, please √ Case Manager ☐ Social Worker ☐

Psychiatrist ☐ Therapist☐ Other ☐

Agency: Click here to enter text. Contact: Click here to enter text. Tel: Click here to enter text.

Other Services providers currently utilized and types of services: Click here to enter text.

Agency: Click here to enter text. Contact: Click here to enter text. Tel: Click here to enter text.Medicaid status pending approval by: Med. Needy/ NJ Care Medicare #: Click here to enter text. Other: Click here to enter text. ‬‬‬

MEDICAL/ MEDICATIONS INFORMATION SHEET (Part of Psychiatrist’s Initial Psychiatric Evaluation)

I.	MEDICAL

A.	Historical

Please record accidents, surgeries, medical conditions, dates of hospitalizations, etc. If client denies same or if information is unavailable at point of referral, please check N/A☐; & date information in the intake when available. Click here to enter text.

Legal

Legal involvement? Y☐ N ☐ Probation: Y☐ N☐ Parole: Y☐ N☐ Describe: Click here to enter text. Outstanding Warrants: Y☐ N☐ Describe: Click here to enter text.

Hx Violence: Physical Assault ☐ Sexual Assault☐ Aggressiveness (Please Circle) Directed At: Family ☐ Residential Staff ☐ Program Staff ☐Peers ☐ Other: Describe: Click here to enter text.

C.	Current

Allergies: Click here to enter text.

Medical Risk Factors: Y☐ N ☐ Describe: Click here to enter text.

Protocols to follow: Click here to enter text. Chronic Physical Condition(s): Click here to enter text. Medical Specialist: Click here to enter text.	Tele: Click here to enter text.

Medical Specialist: Click here to enter text.	Tele: Click here to enter text.

Does client use any ambulatory equipment? Y☐ N☐ Explain: Click here to enter text.

D.	Current Medication Regimen

Please list all medications, psychotropic and medical, which comprise client’s current medication regimen.

Medication: Click here to enter text. Dosage: Click. Schedule: Click here to enter text.

Medication: Click here to enter text. Dosage: Click here to enter text. Schedule: Click here to enter text.

Medication: Click here to enter text. Dosage: Click here to enter text. Schedule: Click here to enter text.

Medication: Click here to enter text. Dosage: Click here to enter text. Schedule: Click here to enter text.

Medication: Click here to enter text. Dosage: Click here to enter text. Schedule: Click here to enter text.

Medication: Click here to enter text. Dosage: Click here to enter text. Schedule: Click here to enter text.

Medication: Click here to enter text. Dosage: Click here to enter text. Schedule: Click here to enter text.

Medication: Click here to enter text. Dosage: Click here to enter text. Schedule: Click here to enter text.

Medication: Click here to enter text. Dosage: Click here to enter text. Schedule: Click here to enter text.

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Who will transport client to appointment? ______________________Phone # (if not by CCBH) ________________

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

Intake Process Per.: ___________Completed: Y N Reason: __________________ Last Day Attended: ___________ Program Schedule: ________________________	Adm. Criteria Met: Yes No Unsure Reason: ___________

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

I have read and reviewed the above information.

Psychiatrist’s Signature: ____________________________________________ Date:_______________