RCRS Screening / Intake Form

Referral / Intake Form

Please provide as much information as possible
Is this referral for you or another person? *

Self-referral Another person
What is your relationship to the person being referred?
Ex. (Mother, MHSB worker, Case Manager, Peer support, Friend, etc.)
Referring Agency
Contact Name
Name of person making the referral
Contact Phone Number
Your Phone not the referral
Extension
Email
example@example.com
Patient Information
Client Name *

First Name Middle Name Last Name Suffix
Today's Date

Month Day Year
Date
Client Date of Birth *

Month Day Year
Date
Age
Client Phone Number *
Client Email
example@example.com
Current Address

Street Address

Street Address Line 2

City State

Zip Code
Reason for No Address

Unknown Homeless
Gender *
Other:
Gender
SSN
NO SSN

Unknown
Race *
Other:
Race
Marital Status *
Other:
Marital Status
Employment status:
Client Insurance *

No Insurance Medicaid Medicare Commerical / Private
Medicaid ID
12-Digit ID
NO Medicaid ID

Unknown
Medicaid MCO
Select MCO
Medicare Policy Info
Other Policy Info
Insurance Card(s)

Browse Files
Upload picture of Insurance ID cards Cancel of
Take Photo of ID Card
Emergency Contact
Name / Relationship
EC Phone Number
Emergency Contact Address (if available)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Medical Data
Presenting Problems - check all that apply *
Do you have upcoming Court / PO apts.? *

Yes No
Probation / Court details
Upcoming Court / PO Apts.
PO / Attorney - Contact
Are you prescribed / taking any current medications? *

Yes No
Current Medications *
Do you have any allergies?

Food Environmental Medication No allergies are known
Do hou have any of the following conditions:

I HAVE NONE OF THESE Asthma Cardiovascular Disease Diabetes Mellitus Tuberculosis Diabetes HIV Hepatitis A/B/C Depression Anxiety Drug/Alcohol Addiction Cancer Dementia / Alzheimer's TB High Cholesterol High Blood Pressure (Hypertension) Chronic Pain COPD Seizures / Neurological Liver Prolems Glaucoma High Cholesterol Epilepsy Sleep problems / Insomnia Kidney Problems
Please describe Existing Medical Problems/Conditions
Any further details or other medical issues not mentioned above
Please describe any previous hospitalizations / Surgeries:
Provide the reason and treatment
Does your Family have a history of Illnesses?

NO - NONE OF THESE Asthma Cardiovascular Disease Diabetes Mellitus Hypertension Tuberculosis Diabetes HIV STD's Depression Anxiety Drug/Alcohol Addiction Cancer Dementia / Alzheimer's Alzheim
Should be Empty:

Referral / Intake Form

Patient Information

Medical Data

Probation / Court details