COMMUNITY CARE BEHAVIORAL HEALTH

PRE-INTAKE FOR ☐ Freehold - ☐ Piscataway

Client’s Name: ______Date: ______

Client Address: ______

City: ______State:______Zip Code: ______Tel: ______

DOB: ______Age: _____S.S.#______Medicaid #:______Approved? Y☐ N☐

Referral Source/ Title:______Tel: ______

Agency: ______Fax: ______

Residence Contact Person(s): ______Tel:______

Presenting Problem/Reason for Referral: ______

______

Presenting Symptoms: ______Hx Suicide Attempts: Y☐ N☐Dates: ______

Other Partial Care Programs Attended: ______

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

Reason for Leaving: ______Dates: ______

Hx Alcohol/Drug Abuse: Y☐ N☐Drug of Choice: ______Date Last Used: ______

Date Span of Most Recent Psychiatric Hospitalization: ______Name of Hospital: ______

Provisional DiagnosesProvided By: ______

______

______

Primary Physician: ______Tel: ______

Primary Psychiatrist: ______Tel: ______

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

Pharmacy:______Tel: ______

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

Agency: ______Contact: ______Tel: ______

Other Services providers currently utilized and types of services: ______

Agency: ______Contact: ______Tel: ______

Medicaid status pending approval by: Med. Needy/ NJ Care Medicare #:______Other:______

Who will transport client to appointment? ______Phone# (if not CCBH)______

Appointment Date: ______Time:_____ Intake Completed on: ______Schedule Started Date: ______

Intake Process per: ______Completed:Y☐ N☐ Reason: ______Last Day Attended: ______

Program Schedule: ______Adm. Criteria Met: Y☐ N☐ Unsure☐ Reason: ______

Pre-Intake Worker’s Signature:______Title:______Date: ______

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. ______

______

B.Legal

Legal involvement? Y☐ N ☐ Probation: Y☐ N☐Parole: Y☐ N☐Describe: ______Outstanding Warrants: Y☐ N☐ Describe: ______

Hx Violence: Physical Assault☐Sexual Assault☐Aggressiveness (Please Circle) Directed At: Family☐Residential Staff☐Program Staff☐Peers☐ Other: Describe:______

C. Current

Allergies: ______

Medical Risk Factors: Y☐ N ☐ Describe: ______

Protocols to follow: ______

Chronic Physical Condition(s): ______

Medical Specialist: ______Tel: ______

Medical Specialist: ______Tel: ______

Does client use any ambulatory equipment? Y☐ N☐ Explain: ______

D. Current Medication Regimen

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

Clozaril? Y☐ N ☐ dosage ______How often blood work? ______Last blood work ______

  1. Medication:______Dosage:______Schedule: ______Noon:______
  2. Medication: ______Dosage: ______Schedule: ______Noon:______
  3. Medication: ______Dosage: ______Schedule: ______Noon:______
  4. Medication: ______Dosage: ______Schedule: ______Noon:______
  5. Medication: ______Dosage: ______Schedule: ______Noon:______
  6. Medication: ______Dosage: ______Schedule: ______Noon:______
  7. Medication: ______Dosage: ______Schedule: ______Noon:______
  8. Medication: ______Dosage: ______Schedule: ______Noon:______
  9. Medication: ______Dosage: ______Schedule: ______Noon:______
  10. Medication: ______Dosage: ______Schedule: ______Noon:______
  11. Medication: ______Dosage: ______Schedule: ______Noon:______

If client is on injectable, date of last injection ______. (Please include dosage and frequency of injection)

I have read and reviewed the above information.

Psychiatrist’s Signature: ______Date:______

Revised 10/17