Language
English (UK)
Referral for Bridge Health (fka Lookout Mountain CSB) IDD Program
Individuals Information
Name
*
Name
Client ID # (if applicable)
Address
*
Address
Indirizzo Riga 2
City
Nazione / Provincia
Post Code
Phone Number
*
Social Security Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Living Situation
Alone
With Parent(s)
Spouse
Children
Friends
Primary Insurance Information
Insurance Information
Medicaid
Medicare
Amerigroup
CareSource
PeachState
WellCare
Private Insurance
Insured Identification Number
Insurance Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the individual have a secondary insurance?
Yes
No
Secondary Insurance Information
Skip section if not applicable
Insurance Information
Medicaid
Medicare
Amerigroup
CareSource
PeachState
WellCare
Private Insurance
Insured Identification Number
Insurance Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Diagnosis Information
Primary Diagnosis
*
Secondary Diagnosis
Other Medical Diagnoses
Referring Agency Information
Agency Name
*
Referral Staff Name
*
First Name
Last Name
Referring Agency Admission Date (date individual came to your agency)
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
E-mail
Medical/Psychiatric Information
Medications
*
(Name, Dose, Frequency)
History of Medication Compliance
Excellent
Good
Fair
Poor
How does individual behave when off medications?
Currently uses alcohol/drugs?
Yes
No
If Yes, please explain
Compliance with treatment plan
Excellent
Good
Fair
Poor
Comments
Psychiatric Hospitalizations
(Hospital Name, Date, Length of Stay)
Psychosocial Treatment Needs
Behavioral Concerns/Comments
*
List all services provided to this individual during the past twelve months
Interpretive Summary (last 90 days)
Living Skills
Rate living skills in the following areas
Doesn't Need Assistance
Needs Some Assistance
Needs Ongoing Assistance
Housekeeping
Food Prep/Storage
Grocery Shopping
Transportation
Communication
(use phone, make appointments)
Leisure time planning
Money Management
Ability to Arrange Healthcare
Interpersonal Skills
Other Information
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