RCRS Screening / Intake Form

Referral / Intake Form

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

Self-referral Another 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 Name Middle Name Last Name Suffix
Today's Date

Month Day Year
Date
Client Date of Birth *

Month Day Year
Date
Age
Client Phone Number *
Client Email
example@example.com
Current Address

Street Address

Street Address Line 2

City State

Zip Code
Reason for No Address

Unknown Homeless
Gender *
Other:
Gender
SSN
NO SSN

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

No Insurance Medicaid Medicare Commerical / Private
Medicaid ID
12-Digit ID
NO Medicaid ID

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

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

Street Address

Street Address Line 2

City State / Province

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

Depression ADHD Anxiety Suicidal Thoughts Bipolar Mood Homicidal Thoughts PTSD
Problematic Substances:

Opioids/Heroin Meth/Stimulants Alcohol Hallucinogens/Exstacy Benzodiazepines Inhalents Cocaine
Substances Remarks
Other Problems

Pregnant Abusive Relationship Homeless Child custody Probation Marital / Significant Other Court Medical
Other Details / Why Treatment Now?
Do you have upcoming Court / PO apts.? *

Yes No
Probation / Court details
Upcoming Court / PO Apts.
PO / Attorney - Contact
Are you prescribed / taking any current medications? *

Yes No
Current Medications *
Do you have any allergies?

Food Environmental Medication No allergies are known
Do you have any of the following conditions:

Abnormal Bleeding Hepatitis A/B/C Abscesses/Ulcers High Cholesterol Asthma Hypertension Brain Injury Kidney Disease Cancer Liver Disease COPD Swelling / Fluid (extremitites) Chronic Pain Seizures / Neurological Diabetes Sleep problems / Insomnia Headaches Thyroid Heart Conditions TB HIV
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 Bleeding Hepatitis A/B/C Abscesses / Ulcers HIV Asthma Hypertension Blood Disorder Kidney Disease Brain Injury Liver Disease Cancer Neurological / Seizures COPD Sleep Issues Diabetes Swelling / Fluid (extremeties) Dementia / Alzheimer's Thyroid Headaches Tuberculosis Heart Conditions
Should be Empty:

Referral / Intake Form

Patient Information

Presenting Problems - check all that apply:

Probation / Court details