Mental Health Association of Orange County



CLIENT INFORMATION FORMDIVISION: FORMCHECKBOX AOABH FORMCHECKBOX BHCOE FORMCHECKBOX CYBH FACILITY: FORMTEXT ?????Date: FORMTEXT ????? FORMCHECKBOX INTAKE FORMCHECKBOX UPDATE FORMCHECKBOX SAME DAY REG / DC(Please Print Clearly and Fill Out the Information Below as Completely as You Can)Person Filling Out Form: FORMCHECKBOX Client FORMCHECKBOX Parent FORMCHECKBOX Guardian FORMCHECKBOX Clinician FORMCHECKBOX Other FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last NameFirst NameMiddle Name FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name You Prefer to Be CalledMaiden NameBirth Name FORMCHECKBOX Same as AboveHave you or an immediate family member ever served in the US Military?Definition of Immediate Family: Parent, Sibling, Child (birth / adopted / step) FORMCHECKBOX Self Only FORMCHECKBOX Immediate Family FORMCHECKBOX Both Self & Immediate Family FORMCHECKBOX None FORMCHECKBOX Decline to State FORMCHECKBOX Unknown FORMTEXT ________/________/________ FORMTEXT ______-______-________Date of BirthSocial Security NumberGender FORMCHECKBOX Female FORMCHECKBOX MaleTransgender: FORMCHECKBOX Female to Male FORMCHECKBOX Male to Female FORMCHECKBOX Unknown FORMCHECKBOX Decline to State FORMCHECKBOX Other FORMTEXT ????? FORMTEXT ?????Sexual Orientation FORMCHECKBOX Bisexual FORMCHECKBOX Gay FORMCHECKBOX Heterosexual FORMCHECKBOX Lesbian FORMCHECKBOX Questioning FORMCHECKBOX Decline to State FORMCHECKBOX Other FORMTEXT ????? FORMTEXT ?????Preferred Gender Pronouns FORMCHECKBOX He / Him / His FORMCHECKBOX She / Her / Hers FORMCHECKBOX They / Them / Theirs FORMCHECKBOX Decline to State FORMCHECKBOX Other FORMTEXT ????? FORMTEXT ?????Have You Gone by Other Names in the Past? FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ????? FORMTEXT ?????Previous Name #1 (Last, First, MI)Previous Name #2 (Last, First, MI)CLIENT DEMOGRAPHICS FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Driver’s License / State ID NumberState of IssueWhere Are You Currently Living? FORMTEXT ????? FORMTEXT ?????Mailing Address (Street or PO Box) FORMCHECKBOX Apt FORMCHECKBOX Unit FORMCHECKBOX Suite # FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ?????CityState ZipCounty of Residence FORMTEXT ????? FORMTEXT ?????Street Address Where You Are Currently Living FORMCHECKBOX Same as Mailing Address FORMCHECKBOX Apt FORMCHECKBOX Unit FORMCHECKBOX Suite # FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????City State Zip FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Home PhoneCell PhoneBusiness PhonePLACE OF BIRTH FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CA County of BirthUS State of BirthCountry of BirthLANGUAGE / RELIGION FORMTEXT ????? FORMTEXT ?????Primary LanguageSecondary Language FORMTEXT ????? FORMTEXT ?????Preferred LanguageFamily Language FORMCHECKBOX Fluent FORMCHECKBOX Limited FORMCHECKBOX None FORMTEXT ????? English Verbal ProficiencyReligious Preference ETHNICITY Are You Spanish, Hispanic or Latino? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown Please Indicate Up to Two Ethnicities That Best Describe You: “1” for Primary and “2” for Secondary___Aleut___Hawaiian Native___Pakistani___Algerian___Hispanic-Other FORMTEXT ????? FORMTEXT ?????___Palestinian___Amerasian___Indian (Asian)___Puerto Rican___Bangladeshi___Iranian___Samoan___Black / African-American___Iraqi___Somalian___Cambodian___Japanese___South or Central American___Caucasian / European/ White___Korean___Spanish___Laotian___Srilankan___Chinese___Lebanese___Thai___Cuban___Mexican___Vietnamese___Egyptian___Native American / Am Indian___Unknown___Eskimo___Other Asian FORMTEXT ????? FORMTEXT ?????___Decline to State___Filipino___Pacific Islander___Other FORMTEXT ????? FORMTEXT ?????___Guamanian(Not Hawaiian / Guamanian / Samoan) FAMILY INFORMATIONClient Marital Status FORMCHECKBOX Single FORMCHECKBOX Married FORMCHECKBOX Divorced FORMCHECKBOX Separated FORMCHECKBOX Widowed FORMCHECKBOX Domestic PartnershipFor how many people are you the Primary Caregiver?Through Age 17Definition of Primary Caregiver: 50% or More of Your Time18 or Older FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Mother’s Last NameMother’s First NameMother’s Middle Name FORMTEXT ????? FORMTEXT ________/________/________Mother’s Maiden NameMother’s Date of Birth FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Father’s Last NameFather’s First NameFather’s Middle NameCLIENT EMPLOYMENT INFORMATIONPlease select the option that best describes your current employment status: FORMCHECKBOX Competitive F/T (>34hrs/wk) FORMCHECKBOX Non-Competitive F/T (>34hrs/wk) FORMCHECKBOX Student FORMCHECKBOX Competitive P/T (<34hrs/wk) FORMCHECKBOX Non-Competitive P/T (<34hrs/wk) FORMCHECKBOX Homemaker FORMCHECKBOX Retired FORMCHECKBOX Volunteer FORMCHECKBOX Actively Looking FORMCHECKBOX Resident / Inmate FORMCHECKBOX Other Definition of Competitive and Non-Competitive Employment:Competitive Employment = Paid employment in the community in a position that is also open to individuals without a disability. This may include positions with ongoing on-site or off-site job-related support services provided (Supported Employment).Non-Competitive Employment = Paid jobs in the community that are open only to individuals with a disability. FORMTEXT ????? FORMTEXT ?????OccupationEmployerCLIENT SCHOOL INFORMATIONHighest Education Completed: FORMCHECKBOX Kindergarten FORMCHECKBOX 1st Grade FORMCHECKBOX 2nd Grade FORMCHECKBOX 3rd Grade FORMCHECKBOX 4th Grade FORMCHECKBOX 5th Grade FORMCHECKBOX 6th Grade FORMCHECKBOX 7th Grade FORMCHECKBOX 8th Grade FORMCHECKBOX 9th Grade FORMCHECKBOX 10th Grade FORMCHECKBOX 11th Grade FORMCHECKBOX 12th Grade (HS Grad or GED) FORMCHECKBOX 1st Year College FORMCHECKBOX Associate Degree FORMCHECKBOX 3rd Year College FORMCHECKBOX Bachelor’s Degree FORMCHECKBOX 1st Year Grad Work FORMCHECKBOX Master’s Degree FORMCHECKBOX 3rd Year Grad Work FORMCHECKBOX Doctorate FORMCHECKBOX None FORMCHECKBOX Unknown FORMCHECKBOX Other FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name of School AttendingName of School ContactContact’s Phone NumberGENERAL MEDICAL CONDITIONSPlease Indicate Any General Medical Conditions: List “1” for Primary and “2” for Secondary.Place a check mark next to any additional General Medical Conditions if you have more than two (2). ____Patient Denies Any Medical Conditions____Hypercholesterolemia ____Allergies____Hyperlipidemia ____Anemia____Hypertension ____Arterial Sclerotic Disease____Hyperthyroid ____Asthma____Hypothyroid ____Back / Neck Pain____Immunologic Disorder ____Blind / Visually Impaired____Infertility ____Blood Disorder (other than Anemia)____Migraines ____Cancer____Multiple Sclerosis ____Carpal Tunnel Syndrome____Muscular Dystrophy ____Chronic Obstructive Pulmonary Disease (COPD)____Musculoskeletal Problem (not back/neck) ____Cirrhosis____Neurologic Disorder ____Congenital Disorders____Obesity ____Congestive Heart Failure____Osteoarthritis ____Cystic Fibrosis____Osteoporosis ____Deaf / Hearing Impaired____Pain (Chronic) ____Dementia____Parkinson’s Disease ____Dermatologic Disorder / Skin Lesions____Physical Disability ____Diabetes____Psoriasis ____Digestive Disorder____Renal Failure / Disease ____Ear Infections____Rheumatologic Arthritis ____Endocrine Disorder____Rheumatologic Disorder ____Epilepsy / Seizures____Sexually Transmitted Disease (STD) ____Gall Bladder Problems____Stroke ____Genitourinary Disorder____Tinnitus ____GERD____Ulcers ____Headaches (not Migraines)____Underweight ____Heart Disease____Other FORMTEXT ????? FORMTEXT ????? ____Hepatitis____Unknown / Not Able to AssessREFERRAL INFORMATIONHow did you find out about our services? FORMTEXT ?????EMERGENCY CONTACTS Who should we contact in case of an emergency?Primary - Client’s Relationship to Emergency Contact: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name (Last, First)Address FORMTEXT ????? FORMTEXT ?? FORMTEXT ?????CityStateZip FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Home PhoneBusiness Phone / Ext.Cell PhoneSecondary - Client’s Relationship to Emergency Contact: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name (Last, First)Address FORMTEXT ????? FORMTEXT ?? FORMTEXT ?????CityStateZip FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Home PhoneBusiness Phone / Ext.Cell PhoneCONSERVATORSHIPAre You on Conservatorship? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMTEXT ?????Client Relationship to Conservator FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Conservator Last NameConservator First NameConservator Middle Name FORMTEXT ????? FORMTEXT ?????Conservator Mailing Address (Street or PO Box) FORMCHECKBOX Apt FORMCHECKBOX Unit FORMCHECKBOX Suite # FORMTEXT ????? FORMTEXT ?? FORMTEXT ?????Conservator Mailing Address CityStateZip FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Home PhoneCell PhoneBusiness Phone / Ext FORMTEXT ????? FORMTEXT ?????Court Case NumberIs Conservator PAPG or Private?254203280543STOPThe last two pages are for clinical use only. Please return this packet to front office staff.00STOPThe last two pages are for clinical use only. Please return this packet to front office staff.11277882745740The last two pages are for clinical use only. Please return this packet to front office staff.STOP00The last two pages are for clinical use only. Please return this packet to front office staff.STOPFOR CLINICIAN USE ONLYCLIENT DEMOGRAPHICSAdmission Living Arrangement FORMCHECKBOX 1-12 (Group Home Level) FORMCHECKBOX 13-14 (Group Home Level) FORMCHECKBOX Acute Psychiatric Inpatient FORMCHECKBOX Board and Care FORMCHECKBOX Cerritos College Hospital FORMCHECKBOX Coastal Community Hospital FORMCHECKBOX Convalescent Home FORMCHECKBOX Costa Mesa College Hospital FORMCHECKBOX Daily Support Req in House/Apt FORMCHECKBOX Extended Care West Anaheim FORMCHECKBOX Extended Care Westminster FORMCHECKBOX Foster Care FORMCHECKBOX Homeless/No Identifiable Res. FORMCHECKBOX IMD (Institution for Mental Disease) FORMCHECKBOX Jail/Correctional Facility FORMCHECKBOX JH (Juvenile Hall) FORMCHECKBOX Joplin Youth Camp FORMCHECKBOX Kaiser Hospital FORMCHECKBOX Medical Hospital FORMCHECKBOX MHRC (MH Rehab Center) FORMCHECKBOX No Support Req in House/Apt FORMCHECKBOX Non-Contracted Facility FORMCHECKBOX OCFC (Orangewood) FORMCHECKBOX Out of State Res Tx Center FORMCHECKBOX Parent/Guardian Home (Minor) FORMCHECKBOX Prison FORMCHECKBOX Psychiatric Hospital - Other FORMCHECKBOX Psychiatric Residential Tx Center FORMCHECKBOX Regional Center Group Home FORMCHECKBOX Residential/Recovery Facility FORMCHECKBOX Res Rehabilitation Facility FORMCHECKBOX RFE (Res Facility for the Elderly) FORMCHECKBOX Room and Board FORMCHECKBOX RTRC (Santa Ana Royale) FORMCHECKBOX Shelter FORMCHECKBOX SNF (Skilled Nursing) FORMCHECKBOX Sober Living Home FORMCHECKBOX Social Rehab Facility FORMCHECKBOX Some Support Req in House/Apt FORMCHECKBOX State Hospital FORMCHECKBOX STEPs MHRC FORMCHECKBOX STEPs Res Rehab Facility FORMCHECKBOX Supported Housing FORMCHECKBOX UCI Med Center FORMCHECKBOX VA Hospital FORMCHECKBOX WMA (West Med – Anaheim) FORMCHECKBOX YGC (Youth Guidance Center) FORMCHECKBOX YLA (Youth Leadership Academy) FORMCHECKBOX Unknown/Not Reported FORMCHECKBOX Other: FORMTEXT ????? SCHOOL INFORMATIONFor Educationally Related Mental Health Services (ERMHS)ERMHS Referral: FORMCHECKBOX No FORMCHECKBOX YesHome School District: FORMTEXT ___________________________Special Education Eligibility (per IEP) FORMCHECKBOX Not Applicable FORMCHECKBOX Autism FORMCHECKBOX Deaf-Blind FORMCHECKBOX Deaf/Hard of Hearing FORMCHECKBOX Developmental Delays (Ages 3-9) FORMCHECKBOX Emotionally Disturbed FORMCHECKBOX Limited IQ FORMCHECKBOX Non-Cat/Med Condition (0-5) FORMCHECKBOX Orthopedically Impaired FORMCHECKBOX Other Health Impaired FORMCHECKBOX Specific Learning Disability FORMCHECKBOX Speech & Language Impaired FORMCHECKBOX Traumatic Brain Injury FORMCHECKBOX Visually ImpairedSpecial Education Setting (per IEP) FORMCHECKBOX Not Applicable FORMCHECKBOX Home Instruction FORMCHECKBOX Non-Public School FORMCHECKBOX Regular Classroom FORMCHECKBOX RSP (Resource Specialized Program) FORMCHECKBOX SDC (Special Day Class) FORMCHECKBOX State School FORMCHECKBOX OtherENCOUNTER INFORMATIONProgram Specialty FORMCHECKBOX Not ApplicableOther: FORMTEXT _____________________BHS Special Population FORMCHECKBOX CalWORKS FORMCHECKBOX NoneTX TEAM INFORMATIONHCA Providers(Last Name, First Name) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Psychiatrist / Nurse PractitionerMedical Physician / Nurse PractitionerCare Coordinator / Case Manager FORMTEXT ????? FORMTEXT ?????ClinicianAuxiliary Service ProviderAuxiliary Provider Type FORMTEXT ?????Service Chief / Program DirectorCYS MHSA Tx Provider TypeLEGAL INFORMATIONCourt / Conservator Status FORMCHECKBOX PC2974 FORMCHECKBOX Probate 1400 FORMCHECKBOX W300 Juvenile Dependent FORMCHECKBOX W5008 (Murphy Conservator) FORMCHECKBOX W5353 (Temp Conservator) FORMCHECKBOX W5358 LPS Conservator FORMCHECKBOX W5686 FORMCHECKBOX W601 Juvenile Status Ward FORMCHECKBOX W602 Juvenile Ward FORMCHECKBOX N/A FORMCHECKBOX Unknown/Not Reported W & I Code Legal Class FORMCHECKBOX Other - Civil Involuntary Status FORMCHECKBOX Other - Criminal Involuntary Status FORMCHECKBOX PC1026 FORMCHECKBOX PC1370 FORMCHECKBOX PC2684 FORMCHECKBOX PC47.6, 47.8 FORMCHECKBOX Sexual Psychopathy / Related Categories FORMCHECKBOX W5150 FORMCHECKBOX W5250 FORMCHECKBOX W5260 FORMCHECKBOX W5270.15 FORMCHECKBOX W5300 FORMCHECKBOX W5585 FORMCHECKBOX W6000 FORMCHECKBOX W709 FORMCHECKBOX N/A FORMCHECKBOX Unknown/Not Reported EOC INFORMATION EOC Start Date FORMTEXT ________/________/_________EOC Name FOR SAME DAY ADMISSION AND DISCHARGE Behavioral Health Treatment Linkage / Referral FORMCHECKBOX ADAS Community Support FORMCHECKBOX AMHS STEPs LPS FORMCHECKBOX CYS Youth Resource Center FORMCHECKBOX ADAS Medical Detox FORMCHECKBOX AMHS STEPs MHRC FORMCHECKBOX Domestic Violence Shelter FORMCHECKBOX ADAS Outpatient FORMCHECKBOX ASO (Administrative Services Organization) FORMCHECKBOX Out of County Behavioral Health Service FORMCHECKBOX ADAS Residential FORMCHECKBOX CYS CAST FORMCHECKBOX Non-Profit Organization FORMCHECKBOX ADAS Social Detox FORMCHECKBOX CYS CAT FORMCHECKBOX PCP (Primary Care Physician) FORMCHECKBOX AMHS Adult Outpatient Services FORMTEXT ????? FORMCHECKBOX CYS CCPU FORMCHECKBOX PEI OC CREW FORMCHECKBOX AMHS Collaborative Court FORMCHECKBOX CYS CEGU OCFC FORMCHECKBOX Psychiatrist Private FORMCHECKBOX AMHS Extended Care West FORMCHECKBOX CYS CEGU Probation FORMCHECKBOX Residential Tx Center for Children FORMCHECKBOX AMHS Extended Care West Anaheim FORMCHECKBOX CYS Contract Regional Outpatient FORMCHECKBOX Student Health Service FORMCHECKBOX AMHS FSP FORMTEXT ????? FORMCHECKBOX CYS County Regional Outpatient FORMCHECKBOX Therapist Private FORMCHECKBOX AMHS LPS Unit (Lanterman - Petris - Short) FORMCHECKBOX CYS CSP Children’s Residential Program FORMCHECKBOX VA Health Care FORMCHECKBOX AMHS Recovery Center FORMTEXT ????? FORMCHECKBOX CYS FSP FORMTEXT ????? FORMCHECKBOX AMHS OAS (Older Adult Services) FORMCHECKBOX CYS Juvenile Drug Court FORMCHECKBOX Client Declined Referral FORMCHECKBOX AMHS PACT(Program Assertive Community Treatment) FORMCHECKBOX CYS OC CAPC (In Home Crisis) FORMCHECKBOX Client Unavailable for Referral FORMCHECKBOX AMHS PACT TAY FORMCHECKBOX CYS Phoenix Academy FORMCHECKBOX N/A No Referral FORMCHECKBOX AMHS Royale MHRC FORMCHECKBOX CYS SCCS TAY Crisis Residential Program FORMCHECKBOX Other FORMTEXT ????? FORMCHECKBOX AMHS Royale TRC FORMCHECKBOX CYS SCCS TAY Social Rehabilitation Program FORMCHECKBOX AMHS SHOPP FORMCHECKBOX CYS TouchstonesDischarge Reason FORMCHECKBOX Client Declined Services FORMCHECKBOX Hospitalized FORMCHECKBOX Linked to BHS Contract Provider FORMCHECKBOX Linked to BHS Provider FORMCHECKBOX Linked to non-BHS Provider FORMCHECKBOX Does Not Meet Medical Necessity (NOA) FORMCHECKBOX Does Not Meet Program Criteria FORMCHECKBOX Other: FORMTEXT ?????Facility EOC / Discharge Date FORMTEXT ________/________/_________62484015875000EOC Name FORMTEXT ????? Provider Signature: ______________________________________Office Staff Initials129349516700500 Print / Type Name: FORMTEXT ????? Date Processed: FORMTEXT ________/________/_________ ................
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