behavioral health services intake admission date · 6/21/2010 · intake admission . intake...

Date______________

Name (First and Last)

Client Gender

If female, maiden name required

Mailing Address: PO Box

City, State, Zip

Physical Address: Street, Apartment

City, State, Zip

Phone Number(s)

Emergency Contact w/phone number

Date of Birth (mm/dd/yyyy)

Social Security Number

Medicaid ID Number

________________________________________________

_ Female Male Other

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

_

Demographics

Race(s): Check all that apply

American Indian Asian Black/African American Caucasian Native Hawaiian Pacific Islander Other Unknown

Alaska Native: Aleut Athabascan Haida Inupiat Tlingit Tsimshian Yupik Other Alaska Native

Ethnicity: Check one

Not Spanish/Hispanic/Latino Chicano Cuban Hispanic Mexican American Puerto Rican Spanish/Hispanic/Latino Unknown

Special Needs: Check all that apply

None No Response Dev Disabled Major Difficulty in Ambulating Moderate to Severe Medical

Problems Severe Hearing Loss or Deaf Traumatic Brain Injury Visual Impairment or Blind Other Unknown

Education: Check one response

If K-11, how many years completed:_________

GED High School Diploma Vocational Training Special Ed Classes Bachelors degree Graduate work (no degree) Master’s degree Doctorate degree Post Secondary 1 yr Post Secondary 2 yrs Post Secondary 3 yr Post Secondary 4+ yrs (no degree) Other Unknown

English Fluency: Check one Excellent Good Moderate Poor Not at all No responseVeteran Status: Check one Never in Military Reserves/Nat. Guard- combat Reserves- no combat Military Dependent Active duty combat Active duty no combat Retired from military Veteran other eras Vietnam vet combat Vietnam vet no combat Unknown

CRNA BHS Intake 1/4

Behavioral Health Services Intake Admission

Intake Information

Intake Staff: ___________________________________________ Date: ____________________________

Initial Contact: Check one

Phone Drop In (Orientation) Hospital/On Call Intervention

Community Service Patrol By Appointment Other

Village: ______________________________________________________

Source of Referral: Check one

ASAP Federal Probation Office of Children’s Services Department of Corrections/Jail Correctional Agency (Probation or Parole) Court – Civil Proceedings Court – Criminal Proceedings Individual/Self Referral Crisis/Respite Care Alaska Native Hospital Detox or Residential Program

API Assisted Living Facility Attorney Developmental Disabilities Residential Program Developmental Disabilities Program Drug Program, Employer (EAP) Halfway House Nursing Home Other Mental Health (not including psychiatrist) Other

Pregnant:___ yes ___no ___unknown If yes, projected due date: __ __/ __ __/ __ __

Injection Drug User: ___ yes ___no ___unknown

Tobacco Use: ____ none ____ cigarettes ____ cigar/pipe ____ smokeless ____ combination

# of Arrests within the last 30 days: ______

If attending school, # of absences within the last 30 days: ______

Presenting Problem(s) Why are you seeking services? __________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Special Initiative: Check all that apply

None Therapeutic Courts Women w/Children Acquired Brain Disorders Adult- Organic Disorder w/out SED Adult- Severe & Persistent Mental Illness Adult- Severe Emotional Disturbance

Fetal Alcohol Syndrome HIV Methadone Persistent & Disabling Personality Disorder Psychiatric Emergency Services Traumatic Brain Injury

CRNA BHS Intake 2/4

Admission Type: ___First Admission ___Readmission

Are you the person seeking services?: Yes No

# of Prior Substance Abuse Treatment Admissions: _______

# of Non-Treatment Substance Abuse Related Hospitalizations in Past 6 Months: _______

# of Prior Mental Health Treatment Admissions: _______

# of Prior Mental Health Hospitalizations: _______

Current Health Status: ___ Poor ___ Fair ___Good ___Very Good ___Excellent

Pharmacotherapy Planned: ___ Yes or ___No

On Psychotropic Medication: ___Yes or ___No

Financial/ Household Information

Employment Status: Check One

Disabled Employed Full Time Employed Part Time Homemaker Armed Forces Resident/Inmate Retired Seasonal Employee/in season Seasonal Employee/out season Student Unemployed/Not seeking work Unemployed/Subsistence Unemployed/Looking for work Not in Labor Force/Other Other

Primary Income Source: Check one

None Alaska Native Corp Dividends Alimony Alaska PFD Employment Public Assistance Parent’s Income Retirement/Disability Pension Social Security Disability Spouse/Significant Income SSI Unemployment Compensation Other Unknown

Expected Payment Source: Check One

Blue Cross/Blue Shield CIGNA Medicaid Client Self Pay Other

Insurance Type: Check One

None Private Insurance VA insurance Other Unknown

Occupation: Check One

Crafts/Operatives Farm Owner/Laborer Laborer (not farm) Professional/Managerial Sales Services/Household None Unknown

Household Income: Check One

0-$999 $1,000-4,999 $5,000-9,999 $10,000-19,999 $20,000-29,999

$30,000-39,999 $40,000-49,999 $50,000 and over No Response Unknown

CRNA BHS Intake 3/4

Who is responsible for payment of services? Self / Other: ____________________________________

Are you a compacting village member? Yes / No If yes which village: ______________________

Please submit your insurance information (Medicaid ID, insurance card, etc.) If you do not submit this information you may be charged for services.

Consent and Authorization

I consent to receive services provided by Copper River Native Association Behavioral Health Services. _______________________________________ ______________ Client Signature Date

_______________________________________ ______________ Guardian Signature (if applicable) Date

I authorize CRNA Behavioral Health Services to release to the insurance carrier such information as necessary for the completion of my claim. This information will generally be limited to diagnosis, dates of service, and person(s) rendering services.

_______________________________________ ______________ Client Signature Date


CRNA BHS Intake 4/4

Household Composition: Check One

Lives alone Lives with adolescents Lives with children Lives with non-relatives Lives with relatives Lives with significant other Other No response

Living Arrangement: Check One

Private Residence without supportive services Private residence with supportive services Homeless Correction/Detention Facility Crisis Residence Halfway House Hospital for Non-psychiatric purposes Hospital for psychiatric purposes Shelter Residential Treatment Nursing home Other Unknown

Marital Status: Check one

Cohabitating Divorced Married Never Married-single Separated Widowed Unknown

Living in Home: Answer all

Number of people living with client: #____

Number of children in household: #____

Number of children in Residential Treatment Setting: #____

Number of children in Residential Tx Setting receiving services: #____

Guarantor Name (First and Last)

Relationship to Patient

Mailing Address: PO Box

City, State, Zip

Physical Address: Street, Apartment

City, State, Zip

Phone Number(s)

Date of Birth (mm/dd/yyyy)

Social Security Number

__________________________________________________

_

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

Race(s): Check all that apply

American Indian Asian Black/African American Caucasian Native Hawaiian Pacific Islander Other Unknown

Alaska Native: Blood Quantum: _______ Aleut Athabascan Haida Inupiat Tlingit Tsimshian Yupik Other Alaska Native

Ethnicity: Check one

Not Spanish/Hispanic/Latino Chicano Cuban Hispanic Mexican American Puerto Rican Spanish/Hispanic/Latino Unknown

Employment Status: Full Time Part Time Student Disabled Unemployed

If employed, list current employer(s): __________________________________

____________________________________________________________________

If a student, list school(s) currently attended: ____________________________

____________________________________________________________________

Please submit your insurance information (Medicaid ID, insurance card, etc.) If you do not submit this information you may be charged for services.

I authorize CRNA Behavioral Health Services to release to the insurance carrier such information as necessary for the completion of my claim. This information will generally be limited to diagnosis, dates of service, and person(s) rendering services.

_______________________________________ ______________ Client Signature Date


CRNA BHS Guarantor 1/1

Behavioral Health Services Guarantor (responsible payer/party) Information

MEDICAL SCREENING FORM Perform with Bio-Psycho-Social Assessment

(Form Physician Approved- Required by Substance Abuse Standards, JAHCO & CARF) Client Name: Client #:

Current Medical Conditions:

Client Signature Date

Do You Have or Have You Had: (Check & describe all that apply to you) X Type Description Major illnesses Severe fatigue after little activity Feeling tired all the time Unusual swelling or lumps Heart problems in self or family Blurred vision or difficulty seeing Shortness of breath with exercise Buzzing or ringing in your ears Swollen feet or ankles Frequent colds or coughs Severe headaches Problems with your sleep or rest Bleeding gums or teeth problems Aching joints or muscles Constipation or diarrhea Unusual thirst or hunger Major injures/surgeries Recent changes in your weight Allergies (foods, drugs, or others) Any problem with urination Blood in your stool or urine Appetite/ability to eat changes Diabetes

Date of last physical exam: Doctor: Date of last dental visit: Dentist: Date of last vision exam: Eye Doctor:

For Females Only - Do You Have or Have You Had: (Check and describe all that apply to you) Any unusual vaginal discharge: Regular periods: Y N Excessive menstrual bleeding: Are your pregnant: Y N

Do you use birth control: Y N Type: Currently on hormone therapy: Y N When was your last pap smear: When was your last pregnancy: ___________

ALASKA SCREENING TOOL

Client Name: __________________________________________ Client Number: ____________________________

Staff Name: ____________________________________________________ Date: ___________________________

Info received from: (include relationship to client) _____________________________________________________

Please answer these questions to make sure your needs are identified. Your answers are important to help us serve you better. If you are filling this out for someone else, please answer from their view. Parents or guardians usually complete the survey on behalf of children under age 13.

SECTION I – Please estimate the number of days in the last 2 weeks (enter a number from 0-14 days): 0-14 days

1. Over the last two weeks, how many days have you felt little interest or pleasure in doing things?......______ 2. How many days have you felt down, depressed or hopeless?...............................................................______ 3. Had trouble falling asleep or staying asleep or sleeping too much?......................................................______ 4. Felt tired or had little energy?................................................................................................................______ 5. Had a poor appetite or ate too much?...................................................................................................______ 6. Felt bad about yourself or that you were a failure or had let yourself or your family down?...............______ 7. Had trouble concentrating on things, such as reading the newspaper or watching TV?.......................______ 8. Moved or spoken so slowly that other people could have noticed?.....................................................______ 9. Been so fidgety or restless that you were moving around a lot more than usual?................................______ 10. Remembered things that were extremely unpleasant?.........................................................................______ 11. Were barely able to control your anger?...............................................................................................______ 12. Felt numb, detached, or disconnected?.................................................................................................______ 13. Felt distant or cut off from other people?.............................................................................................______

SECTION II – Please check the answer to the following questions based on your lifetime. 14. I have lived where I often or very often felt like I didn’t have enough to eat, had to wear

dirty clothes, or was not safe............................................................................................ Yes No 15. I have lived with someone who was a problem drinker or alcoholic, or who used street

drugs................................................................................................................................. Yes No 16. I have lived with someone who was seriously depressed or seriously mentally ill.......... Yes No 17. I have lived with someone who attempted suicide or completed suicide....................... Yes No 18. I have lived with someone who was sent to prison.......................................................... Yes No 19. I, or a close family member, was placed in foster care..................................................... Yes No 20. I have lived with someone while they were physically mistreated or seriously

threatened........................................................................................................................ Yes No 21. I have been physically mistreated or seriously threatened.............................................. Yes No

a. If you answered “Yes”, did this involve your intimate partner (spouse, girlfriend, orboyfriend)?....................................................................................................................... Yes No

DHSS/Division of Behavioral Health Performance Management System Version Date: June 21, 2010

ALASKA SCREENING TOOL SECTION III – Please answer the following questions based on your lifetime. (D/N = Don’t Know)

22. I have had a blow to the head that was severe enough to make me lose consciousness.. Yes No D/N

23. I have had a blow to the head that was severe enough to cause a concussion……………… Yes No D/N If you answered “Yes” to 22 or 23, please answer a-c:

a. Did you receive treatment for the head injury?...................................................... Yes No

b. After the head injury, was there a permanent change in anything?....................... Yes No D/N c. Did you receive treatment for anything that changed?.......................................... Yes No

24. Did your mother ever consume alcohol?.......................................................................... Yes No D/N a. If Yes, did she continue to drink during her pregnancy with you?.......................... Yes No D/N

SECTION IV – Please answer the following questions based on the past 12 months.

25. Have you had a major life change like death of a loved one, moving, or loss of a job?...... Yes No

26. Do you sometimes feel afraid, panicky, nervous or scared?............................................... Yes No 27. Do you often find yourself in situations where your heart pounds and you feel anxious

and want to get away?........................................................................................................ Yes No

28. Have you tried to hurt yourself or commit suicide?........................................................... Yes No

29. Have you destroyed property or set a fire that caused damage?...................................... Yes No

30. Have you physically harmed or threatened to harm an animal or person on purpose?.... Yes No

31. Do you ever hear voices or see things that other people tell you they don’t see or hear?. Yes No

32. Do you think people are out to get you and you have to watch your step?....................... Yes No

SECTION V – Please answer the following questions based on the past 12 months.

33. Have you gotten into trouble at home, at school, or in the community, because of using

alcohol, drugs, or inhalants?............................................................................................. Yes No

34. Have you missed school or work because of using alcohol, drugs, or inhalants?.............. Yes No

35. In the past year have you ever had 6 or more drinks at any one time?............................. Yes No 36. Does it make you angry if someone tells you that you drink or use drugs, or inhalants

too much?........................................................................................................................... Yes No

37. Do you think you might have a problem with alcohol, drug or inhalant use?.................... Yes No

THANK YOU for providing this information! Your answers are important to help us serve you better.

DHSS/Division of Behavioral Health Performance Management System Version Date: June 21, 2010

Infectious Disease Risk Assessment

The following questions are necessary to assess your risk for infectious diseases. You are not required to answer these questions to participate in an assessment/treatment and client confidentiality laws protect all answers.

Client Name: __________________________________________ Client #: ___________

Infectious Disease Risk Yes No ?

Have you seen a health care provider in the past three months

Do you or have you lived on the street or in a shelter

Have you ever been in jail/prison/juvenile detention

Have you ever been in a long-term care facility (mental health hosp, nursing home, rehab)

In the past 3 months, have you traveled outside the US (where:____________________)

Are you a combat veteran

In the past year, have you had a tattoo, body piercing, acupuncture, or contact with blood

Where were you born

How long have you been in the US

Have you lived with anyone diagnosed with TB in the past year

Have you ever been treated for TB

Have you ever been told you have Hepatitis A

Have you ever been told you have Hepatitis B

Have you ever been told you have Hepatitis C

Have you ever used needles to shoot drugs

Have you ever shared needles or syringes to inject drugs

Have you ever had a job where you were at risk for needle sticks or blood contact

In the past year, have you or anyone you had sex with have an STD or Hepatitis

In the past 30 days have you had any of these symptoms lasting more than 2 wks

Nausea

Fever

Drenching night sweats that were so bad you had to change clothes or bed sheets

Productive cough

Coughing up blood

Shortness of breath

Lumps or swollen glands in the neck or armpits

Loss of weight without trying to

Diarrhea lasting more than a week

Brown tinged urine

Women: Missed periods for last two months

Extreme fatigue

Jaundice or yellow eyes

HIV/AIDS/Hepatitis C Risk Yes No ?

Did you receive a blood transfusion before 1992

Have you received blood products produced before 1987 for clotting problems

Was your birth mother infected by Hepatitis C during the time of your birth

Have you been or are you currently on long-term kidney dialysis

Have you had unprotected sex with someone who has the blood disease hemophilia

Have you had unprotected sex with a person who injects drugs

Have you had unprotected sex with a man who has sex with other men

Have you had sex in exchange for money or drugs in order to survive

Have you had unprotected sex with more than one partner in the past 6 months

Have you had sex or shared needles with a person who has AIDS, HIV+, or Hep C +

Have you ever injected drugs, even once

Have you ever been pricked by a needle that may have been infected with HIV or Hep C

Have you ever had a blood test for HIV

If no, would you like to be tested

If yes, was it within the last six months

Have you ever had a blood test for Hepatitis C

If no, would you like to be tested

If yes, was it within the last six months

How would you judge your own risk for being infected with HIV (Please check one)

I know I am infected

I think I am at high risk

I think I am at low risk

I think I am at NO risk

I am not sure what my risk is

How would you judge your own risk for being infected with Hepatitis C (Please check one)

I know I am infected

I think I am at high risk

I think I am at low risk

I think I am at NO risk

I am not sure what my risk is

Client Signature Date

Name: __________________________________________ Date: __________________

Everyone has strengths that they can use to reach their goals. Some of my/my child’s strengths are:

a good sense of humor a driver’s license/vehicle supportive family/friends a good home a strong work ethic strong morals/cultural values/faith patience a good listener education/vocational training caring about others

Explanation/Other: _________________________________________________________________

_________________________________________________________________________________

Some things I may need to increase the quality of my/my child’s life include:

transportation improved physical/mental health financial assistance education or employment opportunities a safe/clean home improved social skills social or family supports a better ability to manage symptoms


_________________________________________________________________________________

Some of my/my child’s abilities, skills, or talents include:

cultural/traditional/subsistence skills school/academic ability artistic/musical talent writing skills athletic/sports ability social/people skills


_________________________________________________________________________________

My preferences regarding services at CRNA BHS include:

Specific appointment days/times A specific type of service


__________________________________________________________________________________________________

Behavioral Health Services Strengths, Needs, Abilities, Preferences (SNAP)

Behavioral Health Services

Consent for services I, ______________________________________________________ voluntarily consent to receive services from Behavioral Health Services. Initial all when received: __________ I have received a copy of CRNA Patient Rights and Responsibilities. __________ I have received a copy of CRNA Grievance Procedure Policy. __________ I have received a copy of CRNA Privacy Practices (HIPAA/CFR 42). __________ I have received a copy of CRNA Billing Practices/Mandatory Legal Fees. __________ I have received a copy of CRNA Sliding Fee Scale. __________ I have received a copy of CRNA Program Policies. __________ I have received a walk-through of relevant facilities. Safety equipment was pointed out to me and safety drills were explained (if applicable). My rights and responsibilities as a client, grievance policy and procedures, confidentiality practices, and all available services have been explained to me in an understandable format, and I understand and agree with them. The sliding fee schedule and billing practices have been explained to me and I understand and acknowledge that the amount agreed upon is reasonable and just. I further acknowledge that I agree to this of my own free will. I understand this statement may be altered any time my circumstances change significantly. I agree to notify this agency of any change in my income, resources or other circumstances pertinent to this statement as soon as possible. My consent to receive services does not waive my legal rights as recognized under Alaska and federal law. ____________________________________ ___________ Signature of Client Date ____________________________________ ___________ Signature of Parent/Guardian (If Applicable) Date ____________________________________ ___________ Signature of Witness Date

CRNA BHS Consent for Services 1/1

behavioral health services intake admission date · 6/21/2010 · intake admission . intake...

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