(26) Disposition Program Referred to **Must complete 26 if 24 is: SCMH Adult Clinic, SCMH Youth Clinic, Adult Contractor or Youth Contractor

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Philip Gallagher
5 years ago
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1 (1) Date Service Requested (2) Call Time a.m. p.m. (3) Caller Phone Number (4) Data Entered By (5) Method or Source of Referral (6) Client Preferred Language (7a) Program Completing Form (7b) Program RU Completing Form (8) Client Name (9) Client Status (10) Caller Name (if other than client) (11) Financial Investigation Date (13) Current Insurance (12) Medi-Cal Subscriber ID (CIN) (14) Medicare ID (15) Intake Notes Presumptive Transfer Information Only (16) County of Jurisdiction (17) PT Placement Agency (18) Medi-Cal Subscriber County (19) Medi-Cal Aid Code (20) SAR/Presumptive Transfer Notes Disposition (21) Is Client AB 109? Yes No (22) Is Client NBRC? Yes No (23) Is Client on Parole? Yes No (24) Disposition (25) Call Type (26) Disposition Program Referred to **Must complete 26 if 24 is: SCMH Adult Clinic, SCMH Youth Clinic, Adult Contractor or Youth Contractor (27) First Offered Assessment Appt. Date (28) Accepted Assessment Appt. Date Page 1 of 5

2 (29) Screening Staff (30) Screening Date (31) Screening Time a.m. p.m. Determine Emergent Status! " # $ % & ' ( ) " * " + * " ' #, - *. / 0, 1 $ & *. " / 2 + # " # 3 + ( * &, 4 5 (32) Is this a life threatening medical emergency? (33) Is this a life threatening psychiatric emergency? Plan and means to kill/seriously harm self or ather right w? (34) Is this a n-life-threatening situation, but imminent danger to self, danger to other(s) or grave disability (inability to provide for/utilize food, clothing or shelter? Crisis Intervention is necessary. (35) Check all that apply for imminent DTS, DTO, GD: Danger to self Danger to others (36) Tarasoff required? If, skip to 41 Gravely disabled (37) Provide additional Tarasoff details (38) Contacting law enforcement? (39) Contacting intended victim? (40) Emergency Status Information (41) Did you screen for other special status that present risk such as child abuse or elder abuse and complete mandated reporting responsibilities? indication to screen for other (42) Did you need to complete a CPS or APS report? (43) Client intake remarks/comments (include presenting problem) Page 2 of 5

3 SYMPTOMS: For each that applies, enter number values 1, 2 or 3, for frequency of the symptom. Total score will determine Level of Care (add all scores and enter in box 44 on page ##) ANXIETY Anxious mood, fearfulness, worry, anxiety attacks, hyper vigilance, avoidance of school/work Enter 3 for daily DEPRESSED Chronic low mood or irritability, marked hypersomnia or frequent lack of sleep, consistent difficulty deriving pleasure from daily activities or interactions, low energy or passive withdrawal Enter 3 for Daily DEFIANT BEHAVIORS Non-compliance with authority requests, talks back to authority, letters or calls from school, loses temper, easily anyed, deliberately anys others, blames others Enter 3 for Daily DANGER TO SELF Enter 1 for Hx of suicidal thoughts Enter 2 for S/I or attempts within past year Enter 3 for Daily S/I, S/I with plan, recent suicide attempt PSYCHOSIS Hallucinations, delusions, paraia (have you ever heard or seen things which other people do t see or hear? Do you ever feel like your eye or ears or playing tricks on you (see shadows or hear your name being called)? Do you have beliefs that you have invented something of great importance or that a celebrity is going to take you out to dinner? Do you think people are following you or are trying to hurt you or poison you?) Enter 1 for only once or twice Enter 2 for previously, but w stable on meds Enter 3 for current or within past 3 months PROBLEMS WITH SLEEP 6 # & ' $ " 8 % " # # + 9 " # ) " " ( $ ( / & : ) " ' # 7 ) ) + 6 ; 7 # ) " " ( $ ( / & : ) " ' # # * 7! + 6 ; 7 # ) " " ( < 6 * " / = & /, > 1 * + ' " # 7 ' & 6 *. $ & % % 7 # + & 6 7 ) < 6 * " / - & / - >, * + ' " # 7 2 " " 3 $ / "? 0 " 6 * < 6 * " /, & 7 + )! SELF HARM BEHAVIORS A 0 * * + 6 ; $ : 0 / ; $ # % / 7 * %. + 6 ; B / 0 : : + 6 ; $ : + * + 6 ; $ ( 0 6 %. + 6 ; $. 7 + / ( 0 ) ) + 6 ; < 6 * " / = & /. + # * & /! < 6 * " / - & /, > 1 * + ' " # 7 ' & 6 *. < 6 * " /, & 7 + )! & / 6 " ' + % 7 ) % 7 / " 2 + *. + 6 ( 7 # * C ' & 6 *. # HYPERACTIVITY/IMPULSIVITY Difficulty # + * * + 6 ; # * + ) ) & / ( 7! + 6 ; 7 * * " 6 * + & 6 $ 7 + ) # * & ( 7! % ) & # " 7 * * " 6 * + & 6 * " * 7 + ) # + + % 0 ) *! & ) ) & ; *. / & 0 ;. 2 + *. + 6 # * / 0 % * + & 6 # $ + ' ( 0 ) # + 9 " : " & / % 7 / / + " # # 7 " *! / + # ; " / & 0 / ; B / ; + 6 * & # * / " " * # E < 6 * " / = & /, > 1 * + ' " # 7 ' & 6 *. $ & % % 7 # + & 6 7 ) < 6 * " / - & / - >, * + ' " # 7 2 " " 3 $ / "? 0 " 6 * < 6 * " /, & 7 + )! & 7 6 ; " / & 0 # + ' ( 0 ) # " % & 6 * / & ) ( / & : ) " ' # Page 3 of 5

4 TRAUMA Experiencing or witnessing a traumatic event (examples: community violence, sexual trauma/assault, domestic violence) Enter 1 for History of Enter 2 for Within the past few years, mild symptoms Enter 3 for Recent trauma, significant PTSD symptoms ANGRY OUTBURST/AGGRESSION Verbally aggressive, temper gets them in trouble at home or school, fights that can become physical, others are aware and intimidated by their temper Enter 3 for Daily or episode of domestic violence IMPAIRMENTS AT SCHOOL/WORK Problems with attendance, poor grades/lack of productivity, disruptive behaviors Enter 1 for Daily, recent suspensions, fired Enter 2 for 2-3 times a week Enter 3 for 3-4 times a month DANGER TO OTHERS Enter 1 for Hx of thoughts to hurt others due to mental illness Enter 2 for H/I within past few years due to mental illness Enter 3 for H/I within past 6 months due to mental illness MANIC BEHAVIORS F / 7 + & # + *! " % / " 7 # 6 " & / # ) " " ( $ ' & / " * 7 ) 3 7 * + 9 " $ ( / " # # 0 / # ( " " %. $ ) + ;. * & " 7 # $. + ;. / + # 3 7 % * * + " # D " 8 % " # # + 9 " # ( " + 6 ; $ # " ) + + # % / " * + & 6 # E < 6 * " / 1 for only once or twice when using drugs Enter 2 for previously, but w stable Enter 3 for current or within past 3 months PSYCHIATRIC HOSPITALIZATION G #! %. + 7 * / + %. & # ( + * 7 ) + H 7 * + & 0 " * 7 6 ; " / * & # " ) 7 6 ; " / * & & *. " / # & / ; / # 7 : + ) + *! < 6 * " / = & /. + # * & /! & < 6 * " / - & / 2 + *. + 6 *. " ( 7 # * " 2! " 7 / # < 6 * " /, & / 2 + *. + 6 *. " ( 7 # * C ' & 6 *. # RELATIONAL PROBLEMS A & 6 ) + % * & / 7 / ; ; $ 2 + *. ( 7 / " 6 * # $ # + : ) + 6 ; # $ & / # + ; % 7 6 * & *. " / $ ) 7 % 3 & 7 : + ) + *! * & # & % + 7 ) + H " & / ) 7 % 3 & / + " # & / # 0 ( ( & / * #! # * " ' 5 I " & / # % 7 0 # + 6 ; # + ; % 7 6 * # * / " # # )! 0 6 % * + & ; < 6 * " / = & /, > 1 * + ' " # 7 ' & 6 *. < 6 * " / - & / - >, * + ' " # 7 2 " " 3 < 6 * " /, & 7 + )! & ' " # * + % 9 + & ) " 6 % " HOUSING/PLACEMENT INSTABILITY Enter 1 for Foster Care or frequent moves Enter 2 for Lack of housing, homelessness SUBSTANCE USE Enter 1 for history of Enter 2 for within the past few years Enter 3 for weekly or daily Page 4 of 5

5 For the following symptoms, if "Yes" please enter "1" to Binging/purging History of Mental Health Treatment Significant weight loss or weight gain within past 3 months Currently on psych medication Obsessive/compulsive thoughts Encopresis/Enuresis Cognitive impairments Victim of human trafficking Significant medical problems Current/recent legal issues (44) SCORE TOTAL for symptoms Level of Care Details *Does the client need an assessment in hours to prevent psychiatric hospitalization due to Danger to Self, Danger to Others or Grave Disability and/or to prevent worsening of...if, then urgent. (45) Is this client URGENT or ROUTINE? Urgent Routine Page 5 of 5

Domestic Violence Client Intake Form

Domestic Violence Client Intake Form Date: Client ID: Client Name: DOB: Petitioner s Place of Birth Race Address: City State Zip Tel. No. Alt. No. Name/Relation of Contact Person Does the person who you