UNITUS FAMILY SERVICES LLC
Initial Screening Form
Referral Name/Source
Name
Individual's First Name
Last Name
MI
Address
Address
Street Address Line 2
City
State
Postal / Zip Code
Zip Code
(Home)
(Cell)
Date of Birth
/
Month
/
Day
Year
Date
Age
Race
Gender
Medicaid Number
Emergency Information:
In case of emergency, contact:
Name
Relationship
Phone
Format: (000) 000-0000.
Address
Address
Street Address Line 2
City
State
Zip
Primary Care Physician:
Name
Phone
Format: (000) 000-0000.
Address
Address
Street Address Line 2
City
State
Zip
Psychiatrist
Phone
Format: (000) 000-0000.
Address
Address
Street Address Line 2
City
State
Zip
Current/Past Services
Current Medications
Previous Intervention(s): Include current and previous psychiatric/substance abuse/mental retardation/medical treatment and hospitalization.
Significant/Presenting Medical Problem(s): Include current psychiatric/substance abuse/mental retardation/medical problem(s).
Reason individual requesting Service(s)
Does individual have ID/DD Waiver?:
Please Select
Yes
No
I Dont Know
Screening Completed By
Date
/
Month
/
Day
Year
Date
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