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Screening Form

Keys to Success Family & Developmental Services

Initial Referring Screening Form

Select Service

Outpatient

Mobile Crisis

Intensive In Home

Community Stabilization

Mental Health Skill Building

First name

Last name

Birthday

Month

Day

Year

Social Security #

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Email

Insurance Company:

Medicaid #

Parent/Legal Guardian: (if minor)

Primary Care Physician / Facility:

Is the individual receiving case management services?

Yes

No

If yes, explain

Have you been prescribed a psychotropic medication in the past 12 months?

Yes

No

List below if able:

Does individual have a diagnosis of mental illness?

Yes

No

List diagnosis

Was the individual hospitalized for Mental Health

Yes

No

*Please include estimated dates of hospitalization

Reason for Referral:

Aggressive Behavior

Difficulty establishing/maintaining normal relationships

Emotional Problems

Inadequate nutrition

Health or safety is jeopardized

Repeated interventions by the mental health, social service, or judicial System

Unable to recognize personal danger

Unable to recognize inappropriate social behavior

Talks to him/herself

Hears Voices

Major Depression

Paranoid Schizophrenic

Additional Comments:

Name of the Person Obtaining the Information:

Date

Month

Day

Year

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