Maverick Mental Health
Client name
First Name
Last Name
Client's Address
House name/no & Street
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Email address
example@example.com
Client DOB
-
Month
-
Day
Year
Date
Ethnicity
Disability
Yes
No
Do you have a Private, Corporate, or Court appointed guardian
Yes
No
Medicare
Yes
No
Primary Diagnosis
Recent History(Check all that apply over the past 12 months)
Self Injurious behavior
Aggressiveee/Violentbehaviours
Medication noncompliance
Drug/Alcohol abuse
High medical needs
Other
Services Interested in
ARMHS
Other
Does this individual have a DA dated within the last 12 months?
Yes
No
Will this client require MNSure Navigator assistance?
Yes
No
Insurance Type
Ucare
Blue Cross
Health Partners
Medica
PrimeWest
Other
Referrer's information
Referrer's Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Case Manager
First Name
Last Name
CM Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
CM Email
example@example.com
Data protection
The client acknowledges and agrees that their information will be stored securely until it is no longer necessary for their treatment or required by law. Maverick Mental Health has the client's consent to contact them using their preferred communication method.
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