INTEREST FORM

This exciting opportunity includes in and out of school therapy as well as literacy enrichment and life skills training! Our program offers transportation, monthly peer group sessions, individual and group counseling, tutoring, dance, art, retreats, and monthly community activities. Topics we plan to address are:

-Interpersonal Skills
-Health & Hygiene
-Managing & coping with stress
-Anger Management
-Self-respect, Self-esteem & Image
-Grief Counseling
-Bullying
-Nutrition
-Communication Skills
-Conflict Resolution
-Time Management
-Money Management

Please complete the bottom portion of this form and return it to a D&T Health Services representative. One of our representatives will contact you within 24 hours to begin participating in programs and answer any questions you may have.

Client Name:

Legal Guardian (if applicable):

Gender:

Date of Birth:

Age:

Race:

Marital Status:

Contact #:

Alternate #

Address:

City:

Zip code:

(REQUIRED) Email Address:

Referred PRP Coordinator’s Name:

Primary care provider:

Phone Number:

Grade:

Social Security #:

Medicaid #:

Narrative Information: Please circle or write three.

Strengths that I have are:

Enthusiastic Trustworthy Creative Discipline Patient Respectful Outspoken Active Determined Dedicated Honest Flexible Effective Communicator Organized Fast Learner Positive Mindset Multi Tasker Solution-Focused Problem-Solver Ability to Relate to Others Active Listener Dependable Genuine Utilizes Good Judgment and Insight Open Minded Good Sense of Humor Good Self Awareness Ability to Make Friends Leader Good Reader Does well in School Follows Directions Polite/Well Mannered Supportive Understanding

Please check off all that apply:

I need help with:

Vocational/Learning

There are days when:

Socially I have:

Barriers I have in day-to-day living:

Check all that applies and give one or two sentences for each box checked.

Please explain below:

Do you have any of the following?

SSI/SSDI?

Jail History?

If yes, when were you released?

Treatment History?

If yes, please list treatments?

Substance Abuse History?

If yes, please list substance(s) used:

And last date of use:

Date of In-take:

DOA:

Client Name:

Full Name

Full Address

D&T Health Services Phone Number:

Cell:

Highest Grade Completed:

D.O.B.:

Age:

Sex:

Race:

Marital Status:

S.S.#

Number of dependent children:

Number of arrests in the last 30 days:

Are you a Veteran?

Emergency contact:

Relationship to Client:

Phone #:

Source of referral:

Reason for seeking treatment in client’s own words:

Sexual preference/orientation:

(Circle One) F/T or P/T Employer:

Insurance/Medical Assistance Number:

MCO:

Primary Care Physician:

Allergies:

Medical Issues:

Mental Health Diagnosis/issues:

Mental health issues in family history:

Primary drug:

Severity:

Route:

Age of 1st time use:

Last use:

Secondary drug:

Severity:

Route:

Age of 1st time use:

Last use:

Tertiary drug:

Severity:

Route:

Age of 1st time use:

Last use:

Quaternary drug:

Severity:

Route:

Age of 1st time use:

Last use:

ELECTRONIC SIGNATURE AND/OR VERBAL CONSENT AGREEMENT

This Agreement governs the rights, duties, and responsibilities of D&T Health Services in the use of an electronic signature for clinical documentation. The undersigned understands that this Agreement describes the obligations to protect his/her electronic signature, and to notify appropriate authorities if it is stolen, lost, compromised, unaccounted for, or destroyed. I agree to the following terms and conditions:

My electronic signature will be valid for one year from date of issuance or earlier if it is revoked or terminated per the terms of this agreement.
I am also providing permission for D&T Health Services to utilize verbal consent for all treatment documents including consent to treat.
I will be notified and given the opportunity to renew my electronic signature each year prior to its expiration. The terms of this Agreement shall apply to each such renewal.
I will use my electronic signature to establish my identity and sign electronic documents and forms.
I will immediately request that my electronic signature be revoked if I discover or suspect that it has been or is in danger of being lost, disclosed, compromised, or subjected to unauthorized use in any way. For the purposes of authorizing and authenticating electronic health records, my electronic signature or verbal consent has the full force and effect of a signature affixed by hand to a paper document.
I further agree that, for the purposes of authorizing and authenticating electronic health records, my electronic signature has the full force and effect of a signature affixed by hand to a paper document.

Print Client Name

First NameLast Name

Print Client/Guardaian Signature

First NameLast Name

Today's Date

Date

INTEREST FORM

CLIENT FACE/INFORMATION SHEET

CURRENT MEDICATIONS for medical or mental health issues: