Please indicate any changes in the past 30 days to the items below: If no changes, please type N.A.
Client Name
*
Gender
*
Ethnicity
*
Date Of Birth
*
/
Month
/
Day
Year
Date
Social Security Number
*
Client Contact Number
*
Address
*
Client Address
Street Address Line 2
City/State/Zip
State / Province
Postal / Zip Code
Authorized Representative (AR) Name/Address
AR Contact Number
Strengths:
Please indicate any changes in the past 30 days to the items below: If no changes, please type N.A.
1.
*
2.
3.
Resources:
Please indicate any changes in the past 30 days to the items below: If no changes, please type N.A.
1.
*
2.
3.
1. Has Social, Behavioral, Developmental, and Family History and Supports changed in past 30 days?:
*
No changes in the past 30 days
Yes
If yes, please describe
2. Has Cognitive functioning including strengths and weaknesses changed in past 30 days?:
*
No changes in the past 30 days
Yes
If yes, please describe below:
3. Has Employment, vocational, and educational background changed in past 30 days?:
*
No changes in the past 30 days
Yes
If so, please describe below:
4. Has Financial resources and benefits changed in past 30 days?:
*
No changes in the past 30 days
Yes
If yes, please describe below:
5. Has Health history and current medical care needs (to include: allergies, recent physical complaints and medical conditions, nutritional needs, chronic conditions, communicable diseases, restrictions on physical activities, past serious illnesses, serious injuries, hospitalizations, serious illnesses and chronic conditions of the individual's parents, siblings, and significant other in the same household, current and past substance use including alcohol, prescription and non-prescription medications and illicit drugs)changed in past 30 days?:
*
No changes in the past 30 days
Yes
If yes, please describe below:
6. Has Medication, food and other allergies changed in past 30 days?:
*
No changes in the past 30 days
Yes
If yes, please describe below:
7. Has past serious illnesses, serious injuries, and medical hospitalizations changed in past 30 days?:
*
No changes in the past 30 days
Yes
If yes, please describe below:
8. Has Chronic and Significant medical problems/conditions and dental probs -Diabetes -HBP -Heart Disease -Asthma - COPD -HEP -C -HIV -TB changed in past 30 days?:
*
No changes in the past 30 days
Yes
If yes, please indicate below:
9.Has Psychiatric and substance use issues including current mental health or substance use needs, presence of co-occurring disorders, history of substance use or abuse, and circumstances that increase the individual's risk for mental health or substance use issues changed in past 30 days?:
*
No changes in the past 30 days
Yes
If yes, please describe below:
10. When was your last use/how long have you been clean?
*
11. Any lapse in the last 30 days?
*
No lapse in last 30 days
Yes
If so, please indicated drug of choice.
12. Has Relevant criminal charges or convictions and probation or parole status changed in past 30 days?:
*
No changes in last 30 days
Yes
If yes, please describe below:
13.Has Housing arrangements changed in past 30 days?:
*
No changes in the past 30 days
Yes
If yes, please describe below:
14.Has Ability to access services (including transportation needs) changed in past 30 days?:
*
No changes in the past 30 days
Yes
If yes, please describe below:
15.Has your Current Physical Health Medications changed in past 30 days?
*
No changes in the past 30 days
Yes
If yes, please describe changes to medication below
Medication
Dosage
Freq.
Date
/
Month
/
Day
Year
Date
Prescriber
Response
Response Notes
16. Has your current Psychiatric Medications changed in the past 30 days?
*
No changes in the past 30 days
Yes
If yes, please describe below:
Medication
Dosage
Freq.
Date
/
Month
/
Day
Year
Date
Prescriber
Response
Response Notes
Client Signature
*
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