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Screening Assessment
Please fill in the form below
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1
Patient Name
*
This field is required.
First Name
Middle Name
Last Name
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2
Patient Date of Birth
*
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-
Month
Day
Year
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3
Patient Gender
*
This field is required.
Male
Female
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4
Submitted By: (Enter Name)
*
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First Name
Last Name
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5
Submitter E-mail
*
This field is required.
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6
Phone Number
*
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Area Code
Phone Number
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7
Information Provided By:
*
This field is required.
Social Worker
Guardian
Self
Social Worker
Guardian
Self
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8
Does Patient have a Legal Guardian?
*
This field is required.
Yes
No
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9
If Yes, Guardian Name:
First Name
Last Name
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10
Current Living Situation:
*
This field is required.
Homeless
Hospital
Group Home
Other
Other
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11
If Other, Please Specify
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12
Select Supportive Services that the Patient currently has:
*
This field is required.
Medication Management
PSR
ACTT Services
None
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13
Is Family Actively in Patient's Life:
*
This field is required.
Yes
No
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14
Does Patient have any pending court cases:
*
This field is required.
Yes
No
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15
Is Patient on Probation or Parole:
*
This field is required.
Yes
No
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16
Is Patient a Registered Sex Offender:
*
This field is required.
Yes
No
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17
Is Patient Medicaid Active:
Yes
No
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18
Does Patient have Special Assistance (SA):
*
This field is required.
Yes
No
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19
Does Patient have Social Security (SI) setup:
*
This field is required.
Yes
No
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20
Will the Patient funding source be Private Pay:
*
This field is required.
Yes
No
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21
If Yes, How much per month:
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22
Does Patient have a Rep Payee:
*
This field is required.
Yes
No
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23
If Yes, Rep Payee Name:
First Name
Last Name
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24
Does Patient have a Case Worker:
*
This field is required.
Yes
No
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25
If Yes, Case Worker Name:
First Name
Last Name
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26
Attach FL-2 and CCA
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