Forensic Assertive Community Treatment Form (FACT)
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Do you live in Salt Lake County?
Yes
No
Do you have Medicaid?
Yes
No
If yes, Medicaid ID number:
Do you have an open court case?
Yes
No
Are you currently on probation or parole?
Yes
No
Have you received a mental health diagnosis from a doctor or therapist in the past?
Yes
No
If yes, what diagnosis(es)?
Are you currently taking any psychiatric medications?
Yes
No
If yes, which ones and what clinic and/or what provider is prescribing them?
How can we reach you or the individual you are referring?
Submit
Should be Empty: