Intake Form -

CLIENT'S INFORMATION

First Name

Last Name

DOB

AGE

GENDER

MALE FEMALE

SEXUAL ORIENTATION

MEDICAID NUMBER (MA#)

ADDRESS (STREET)

CITY

STATE

ZIP

PHONE - HOME

PHONE - CELL

PHONE - WORK

CURRENTLY EMPLOYED AT

EMPLOYER PHONE NUMBER

IS THE CLIENT A CHILD FOR WHOM COURTS HAVE ADJUSTED THIER LEGAL STATUS?

YES NO

LEGAL GUARDIAN INFORMATION

BIOLOGIGAL PARENT

YES NO

RELATIONSHIP TO CLIENT

GUARDIAN FIRST NAME

GUARDIAN LAST NAME

IS THE ADDRESS THE SAME AS THAT OF THE CLIENT

YES NO

GUARDIAN ADDRESS (STREET)

CITY

STATE

ZIP

PHONE - HOME

PHONE - CELL

PHONE - WORK

EMERGENCY CONTACTS

1. NAME

1. RELATIONSHIP TO CLIENT

1. PHONE - HOME

1. PHONE - CELL

1. PHONE - WORK

2. NAME

2. RELATIONSHIP TO CLIENT

2. PHONE - HOME

2. PHONE - CELL

2. PHONE - WORK

HIGHEST LEVEL OF EDUCATION

EDUCATION LEVEL (SELECT ONE)

SCHOOL NAME (OPTIONAL)

SCHOOL PHONE (OPTIONAL)

SCHOOL FAX (OPTIONAL)

PRESENTING PROBLEMS AT SCHOOL (OPTIONAL)

CLIENT NEEDS

EXPLAIN (REQUIRED)

CONSENT TO PRP SERVICES

PRP SERVICES

ON-SITE OFF-SITE COMBINED ( ON-SITE/OFF-SITE

I AFFIRM THAT I WAS EXPLAINED TO AND UNDERSTAND ALL INFORMATION REGARDING CAREREGION INC. PRP ORIENTATION.

YES NO

CONSENT ROLE (SELECT THE ROLE THAT APPLIES)

PARENT/GUARDIAN MINOR ADULT

PRP Client Consent

PRP CLIENTS CONSENT

TREATMENT

I understand that as a client of CAREREGION INC., I have the right to appreciate evaluation, diagnosis and individualized rehabilitation plan in a timely and acceptable manner. I further understand that I have the right to be informed about options available for rehabilitation, the content, goals and objective of the rehabilitation including the nature and significant possible negative results of my rehabilitation. I understand that I have the right to withdraw my consent to the treatment plan, or rehabilitation services at any time, in writing.

PARTICIPATION

I, the Client (or parent/guardian on behalf of the Client), hereby confirm that I am interested and willing to enter into and actively participate in The Psychiatric Rehabilitation Program (PRP) at CAREREGION INC. I agree to participate in the development of Individual Rehabilitation Plan (IRP) and maintaining personal goals. If program staff should need copies of any additional tests, or lab results, including physical, psychological or social assessments, then I will assist in providing them.

TRANSPORTATION

I hereby authorize CAREREGION INC. as my treatment provider to transport me or my child (a minor) and other significant family members as necessary to facilitate my care. I understand that CAREREGION INC. is providing this service solely as a compliment and will only do so whenever feasible and safe.

RISK MANAGEMENT

Safe, effective, and efficient services.
CAREREGION INC. is aware of all its current risks.
CAREREGION INC. can allocate resources in an appropriate manner to manage its risks.
Whenever possible, the risk of injury, loss of persons served, staff, or the organization is managed in a way that minimizes the risk.
CAREREGION INC. meets its current requirement to comply with Federal and State Health and Safety Laws and Requirements.

RESPONSIBILITY

The Client: I hereby verify that as a client of CAREREGION INC. that I will not bring concealed weapons, drugs (illicit or licit), alcohol, or other contraband onto any CAREREGION INC. facilities or events.

Members of Staff: It is the responsibility of CAREREGION INC. employees to:

Understand risk management policy and procedure.
Be alert to risk identification, assessment, reporting, and management.
Report risks through the line of management so appropriate action can be taken.

Management: Responsibility within individual disciplines is delegated to the following managers:

The Chief Executive Officer is responsible for strategic risk management.
The Program Director is responsible for overall day-to-day risk management and to ensure effective risk management is taking place within the program.
The Program Coordinator is responsible for day-to-day client crisis and risk management.

Signing below states that you consent to participate, to be treated, to be transported, and to avoid risk at CAREREGION INC.

I have read and understand the PRP consent information above (Treatment, Participation, Transportation, Risk Management, and Responsibility) and I agree.

SERVICE SELECTION

Only off-site PRP services Only on-site PRP services Both on-site and off-site PRP services

Legal Guardian (Court Determined)

YES NO

Somatic Medical Problems

YES NO

Somatic Follow-up

YES NO

Has PCP (Primary Care Provider)

YES NO

Yes No How often (optional)

If No: timeframe for referral (optional)

SECTION III

Seeing a Psychiatrist?

Seeing a Therapist?

Seeing a PCP (Primary Care Provider)?

In Case Management?

Current Suicidal Ideation?

Current Homicidal Ideation?

Legal status (charges/convictions)

On Probation?

Access to weapons?

ELECTRONIC SIGNATURES

Signature Field

Signature (Required)

Signature Field

Signature (Optional)

DATE

PRINT NAME

POSITION

DIAGNOSIS REVIEW (STAFF ONLY)

REVIEWED BY

CREDENTIALS

DATE

Signature Field

ELECTRONIC SIGNATURE

INTAKE FORM

Please complete all required fields. Dates are in MM/DD/YY format

CLIENT'S INFORMATION

LEGAL GUARDIAN INFORMATION

EMERGENCY CONTACTS

HIGHEST LEVEL OF EDUCATION

CLIENT NEEDS

CONSENT TO PRP SERVICES

SECTION III

ELECTRONIC SIGNATURES

DIAGNOSIS REVIEW (STAFF ONLY)