RCRS Screening / Intake Form

Referral / Intake Form

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

Self-referralAnother 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 NameMiddle NameLast NameSuffix
Today's Date

MonthDayYear
Date
Client Date of Birth*

MonthDayYear
Date
Age
Client Phone Number*
Client Email
example@example.com
Current Address

Street Address

Street Address Line 2

CityState

Zip Code
Reason for No Address

UnknownHomelessOther
Gender*
Other:
Gender
SSN
NO SSN

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

No InsuranceMedicaidMedicareCommerical / PrivateOther
Medicaid ID
12-Digit ID
NO Medicaid ID

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

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Presenting Problems - check all that apply:
Mental Health Problems Psychiatric Problems

DepressionADHDAnxietySuicidal ThoughtsBipolar MoodHomicidal ThoughtsPTSDOther
Problematic Substances:

Opioids/HeroinMeth/StimulantsAlcoholHallucinogens/ExstacyBenzodiazepinesInhalentsCocaineOther
Substances Remarks
Other Problems

PregnantAbusive RelationshipHomelessChild custodyProbationMarital / Significant OtherCourtMedical
Other Details / Why Treatment Now?
Do you have upcoming Court / PO apts.?*

YesNo
Probation / Court details
Upcoming Court / PO Apts.
PO / Attorney - Contact
Are you prescribed / taking any current medications?*

YesNo
Current Medications*
Do you have any allergies?

FoodEnvironmentalMedicationNo allergies are knownOther
Do you have any of the following conditions:

Abnormal BleedingHepatitis A/B/CAbscesses/UlcersHigh CholesterolAsthmaHypertensionBrain InjuryKidney DiseaseCancerLiver DiseaseCOPDSwelling / Fluid (extremitites)Chronic PainSeizures / NeurologicalDiabetesSleep problems / InsomniaHeadachesThyroidHeart ConditionsTBHIVOther
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?

Abnormal BleedingHepatitis A/B/CAbscesses / UlcersHIVAsthmaHypertensionBlood DisorderKidney DiseaseBrain InjuryLiver DiseaseCancerNeurological / SeizuresCOPDSleep IssuesDiabetesSwelling / Fluid (extremeties)Dementia / Alzheimer'sThyroidHeadachesTuberculosisHeart ConditionsOther
Should be Empty:

Referral / Intake Form

Patient Information

Presenting Problems - check all that apply:

Probation / Court details