* = Required Information
Complete upon service initiation and update as least ANNUALLY
IDENTIFYING INFORMATION
Name
*
Phone
*
A Helping Hand Site
Date of Birth
Address
*
Marital Status
Date Of Service Initiation
Religious Preference
Gender
*
Male
Female
Race
Height
Weight
Hair Color
Eye Color
Distinguishing Characteristics/Identifying Marks
Preferred Language
IDT approved electronics
IDT approved alone time
Most recent CSSP/ISP date
or Meeting Minutes date with Request for current CSSP/ISP
IDENTIFICATION INFORMATION
Social Security Number
State ID Number
Medicare Number
Part A Effective Date
Part B Effective Date
Medical Assistance Number
Straight MA?
Yes
No
If no, SNBC Provider (i.e. UCare)
SNBC Member Number
Medicare Part D Number
Medicare Part D Provider
County of Financial Responsibility
Financial County Case Number
Waiver Type
Representative Payee
LEGAL INFORMATION
Legal Representative
Self
Guardian
Conservator
Commitment Status
None
MI
MI&D
Effective dates of commitment
Jarvis Order
Yes
No
If yes, effective date of Jarvis Order
Provisional Discharge
Yes
No
If yes, from where?
Probation
Yes
No
If yes, date of expected release from probation
BCA Registration Status
Offender Risk Level Assigned
MEDICAL INFORMATION
Diagnosis
Allergies
Seizure Protocol
Maladaptive Behaviors
Medical Concerns
Prescribed Psychotropic Medications?
Yes
No
Advanced Health Care Directive in place?
Yes
No
Advanced Health Care Directive in place?
Glasses
Hearing Aid
Walker/Cane
Wheelchair
Contacts
Emergency
Name
Address
Telephone
E-mail Address
Parents
Name
Address
Telephone
E-mail Address
Legal Representative
Name
Address
Telephone
E-mail Address
Case Manager
Name
Address
Telephone
E-mail Address
Behavioral Health Social Worker
Name
Address
Telephone
E-mail Address
Financial Worker
Name
Address
Telephone
E-mail Address
Residential Contact
Name
Address
Telephone
E-mail Address
Work Program Contact
Name
Address
Telephone
E-mail Address
Treatment Program Contact
Name
Address
Telephone
E-mail Address
Probation Officer
Name
Address
Telephone
E-mail Address
Psychologist (Individual)
Name
Address
Telephone
E-mail Address
Psychologist (Group)
Name
Address
Telephone
E-mail Address
Psychiatrist
Name
Address
Telephone
E-mail Address
Physician
Name
Address
Telephone
E-mail Address
Pharmacy
Name
Address
Telephone
E-mail Address
Dentist
Name
Address
Telephone
E-mail Address
Audiology
Name
Address
Telephone
E-mail Address
Ophthalmologist
Name
Address
Telephone
E-mail Address
Endocrinologist
Name
Address
Telephone
E-mail Address
Neurologist
Name
Address
Telephone
E-mail Address
Podiatrist
Name
Address
Telephone
E-mail Address
Chiropractor
Name
Address
Telephone
E-mail Address
Dermatologist
Name
Address
Telephone
E-mail Address
Urologist
Name
Address
Telephone
E-mail Address
Cardiologist
Name
Address
Telephone
E-mail Address
Occupational Therapist
Name
Address
Telephone
E-mail Address
Dermatologist
Name
Address
Telephone
E-mail Address
Admission Signatures
Admission Date
Person Receiving Services
Date
Legal Representative
Date
Case Manager
Date
Submit