BENGORDONCENTERInitials
DATE: _____/_____/______CLIENT REQUEST FOR SERVICESSystem Assign.#:
Face to Face Phone ID#:
IDENTIFYING INFORMATION:
Name: Date of Birth:
First Middle InitialLast
Social Security #: -- Male Female
Do you have a legal guardian? Yes NoParent/ Guardian Name:
Do you have Full Partial or No custody
*Request copy of divorce decree and newest custody information to have available no later than first visit
For partial custody – inform client must have both parents consent for treatment
For no custody – inform client must have full custodial guardian present during intake
Are you a DCFS Ward? Yes NoCase-Manager Name:
Street Address: Home ph. #: ( )
City: State: Work ph. #: ( )
Zip Code: County: Cell ph. #: ( )
Mailing Address (if different from above):
EMERGENCY CONTACT: PHONE (_____)
Primary language/method of communication: Needs an interpreter? Yes No
HEALTH COVERAGE:
Private Insurance ______POC DCFS SASS DCFS Contract OMH SASS
Medicaid Medicare Sliding Scale
Other
PRESENTING PROBLEM:
Referral source:
Client is Court Ordered Yes No *If yes, must provide court order and police report before scheduling
Why are you seeking services now?
Mental Health
Substance Use
Other
BGC ADMISSION:
PROGRAM: MH(A) MH(C&A) MH(RS) ASA(A) ASA(C&A) EXCEL WEEKEND DUI
OSR – Must have comprehensive assessment from therapist.
Discovery House- Must have completed face-face interview with Discovery House Director and received a confirmation of eligibility
PSYCHOLOGICAL ASSESSMENT- Medicaid clients must be current clients or need to be opened to a Mental Health team first.
Counselor Preference: Male Female Why?
DATE OF INTAKE: THERAPIST:
DATE OF INTAKE: THERAPIST:
DATE OF INTAKE: THERAPIST:
DEKALB OFFICESANDWICH OFFICE
Client Name: DOB: ID#:
RESPIRATORY SCREENING:
Have you ever had history of positive TB skin test, active tuberculosis or been in contact recently with anyone with active tuberculosis?
Yes No If yes, add client to TB list and request current clearance.
Clearance received:Yes NoDate of expiration:
Have you arrived in the U.S. within the past 5 years or been out of the country in the last year? Yes No
Have you ever been diagnosed with a drug-resistant bacterial infection? Yes No (If yes, consult with nurse)
PRIMARY CARE INFORMATION:None (please make sure referral form is in intake packet) Refused to give information
Primary Care Physician: Phone Number:
Address:
RISK ASSESSMENT: (If yes to any below, attach a blue crisis note)
Are you having current thoughts of self harm?None Yes *If yes, connect with ECASP therapist
Are you having current thoughts of harming others? None Yes *If yes, connect with ECASP therapist
Do you feel that you are immediately in danger? No Yes *If yes, connect with ECASP therapist
Do you feel hopeless about your future?No Yes *If yes, connect with ECASP therapist
Does person present as emotionally labile?No Yes *If yes, connect with ECASP therapist
QMHP Signature Date:
LPHA Signature Date:
5/09