Intake Form

First Name *

Last Name *

Email *

Date Of Birth *

MA#

Race

Behavioral Diagnoses

295.90/F20.9 Schizophrenia

295.40/F20.81 Schizophreniform Disorder

295.70/F25.1 Schizoaffective Disorder, Depressive

298.9/F29 Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

295.70/F25.0 Schizoaffective Disorder, Bipolar Type

298.8/F28 Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

297.1/F22 Delusional Disorder

296.33/F33.2 MDD, Recurrent Episode, Severe

296.34/F33.3 MDD, Recurrent, With Psychotic Features

296.43/F31.13 Bipolar I, Most Recent Manic, Severe

296.53/F31.4 Bipolar I, Most Recent Depressed, Severe

296.40/F31.0 Bipolar I, Most Recent Hypomanic

296.7/F31.9 Bipolar I Disorder, Unspecified

296.44/F31.2 Bipolar I, Most Recent Manic, with Psychosis

296.54/F31.5 Bipolar I, Most Recent Depressed, w/o Psychosis

296.40/F31.9 Bipolar I, Most Recent Hypomanic, Unspecified

296.89/F31.81 Bipolar II Disorder

301.83/F60.3 Borderline Personality Disorder

301.22/F21 Schizotypal Personality Disorder

296.80/F31.9 Unspecified Bipolar Disorder

Primary Medicinal Diagnosis

Social Elements Impacting Diagnoses

None

Access to Health Care

Housing Problems

Social Environment

Educational

Legal System/Crime

Occupational

Homelessness

Financial

Primary Support

Unknown

Other Psychosocial/Enviro.

If client does not have Medical Assistance: SS#

This individual has a serious mental illness which has required the intervention of the Public Mental Health System in the last two years:

Yes

No

Individual experiences at least three of the following

Inability to maintain independent employment

Need or assistance with basic living skills

Inability to procure financial assistance due to cognitive disorganization

Social behavior that results in interventions by the mental health system

Severe inability to establish or maintain social supports

Current Medications

Is the individual med compliant

Yes

No

Presenting Symptoms: Please include hx of SI and HI

Criminal Hx

Yes

No

Social Skills

community integration activities

developing natural supports

developing linkages with and supporting the individual’s participation in community activities.

Independent living skills

skills necessary for housing stability

community awareness

mobility and transportation skills, money management

accessing available entitlements and resources

supporting the individual to obtain and retain employment, Health promotion and training

individual wellness self management and recovery

Most Recent Psychiatric Hospitalization

Date

Referring Mental Health Professional Signature and Credentials

Date

Referring Professionals Name

Location and Phone Number

Treating Therapist

Phone

Treating Therapist

Phone