Behavioral Health Care Screening Form
Who can Odyssey contact about this referral?
Contacts phone number?
Please enter a valid phone number.
Contacts email address?
example@example.com
Name of the Client being Referred
*
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Date
What county do you live in (Prior to incarceration if it applies)
What other States have the client lived in?
GENDER PREFERENCE
Please Select
MALE
FEMALE
FEMALE TO MALE
MALE TO FEMALE
NON-BINARY
Is this a CATS referral/transfer?
YES
NO
FUNDING
Please Select
Medicaid
Medicaid PENDING
Commercial Insurance
UNFUNDED
Please Select the recommend Program
Please Select
ADULT RESIDENTIAL
YOUTH RESIDENTIAL
PARENTS PROGRAM
INTENSIVE OUTPATIENT
GENERAL OUTPATIENT
DAY TREATMENT
What is the client's level of proficiency with ENGLISH?
Please Select
EXCELLENT
GOOD
FAIR
POOR
What is the Clients preferred DRUG OF CHOICE IN THE LAST 6 MONTHS (or prior to INCACERATION if applies)
*
When was the client's LAST DATE of USE?
-
Month
-
Day
Year
Date
What SUBSTANCE(s) has the client USED IN THE LAST WEEK?
Is this Client currently on MAT?
Please Select
BUPRENORPHINE
METHADONE
NALTREXONE
SUBLOCADE
SUBUTEX
VIVATROL
NO
Interested
Is the Client currently on Methadone?
Where is the Client currently taking Methadone?
Is the Client PREGNANT?
Yes
No
Has the client attempted suicide IN THE LAST 30 DAYS?
Yes
No
Does the Client have or had ANY OF THESE DIAGNOSIS?
SCHIZOPHRENIA
BIPOLAR DISORDER
MAJOR DEPRESSIVE DISORDER
ANXIETY DISORDERS
BORDERLINE PERSONALITY DISORDER,
POST-TRAUMATIC STRESS DISORDER (PTSD)
EATING DISORDERS
OBSESSIVE-COMPULSIVE DISORDER (OCD)
SCHIZOAFFECTIVE DISORDER
NONE
Has the Client EVER been prescribed ANY of these MENTAL HEALTH medications?
HALDOL
THORAZINE
PROLIXIN
RISERIDONE
RISPEDRDAL
ZYPREXA
ABILIFY
LOXITANE
MOBAN
INVEGA
LATUDA
CLOZARIL
REXULTI
BENZODIAZEPINE
MEDICAL MARIJUANA
ADDERALL
RITALIN
VYVANSE
DEXEDRINE
NONE
Has the client EVER been prescribed ANY of these PHYSICAL HEALTH MEDICATIONS?
Please Select
INSULIN
OXYGEN
MEDICAL MARIJUANA
AMBIEN
LUNESTA
GABPENTIN
LYRICA
SOMA
FLEXERIL
ROBAXIN
BACLOFEN
PAIN MEDICATION
ANTICOAGULANTS
NONE
Does the Client have ANY OF THE FOLLOWING MEDICAL CONDITIONS?
Please Select
HIV/AIDS
DIABETES
HEPATITIS/CIRRHOSIS
TUBERCULOSIS
ASTHMA/COPD/SLEEP APNEA
TRAUMATIC BRAIN INJURIES
HYPERTENSION/HIGH BLOOD PRESSURE
GI BLEED
HEART DISEASE
SEIZURE DISORDER
ACTIVE WOUND OR ABSCESS
PAIN MANAGEMENT
NONE
Has the Client BEEN HOSPITALIZED IN THE LAST 14 DAYS?
Yes
No
If the Client has BEEN HOSPITALIZED IN THE LAST 14 DAYS, WHERE?
Does the Client have CHILDREN IN DCFS CUSTODY UNDER THE AGE OF 11?
Yes
No
Additional comments that ODYSSEY may want to consider in admitting this client :
Submit
Should be Empty: