Pre-Admission Screening

Pre-Admission Screening

(for Direct Admissions)
When you're ready to refer someone, please fill out this form. Complete all relevant sections and explain any "yes" answers in the questionnaire. You can skip any fields that don't apply to your situation. Once finished, submit this form. Need more help? Email admissions@suncloudhealth.com or call us at to 866-729-1012.
Name of person completing form:*
Date*

MonthDayYear
Date
Client Demographic Information
Client Legal Name: *
Client Preferred Name:
Client Pronouns:
Client Date of Birth:

MonthDayYear
Date
Client Phone Number:*
Please enter a valid phone number.
Client Email Address:*
example@example.com
Parent/Guardian Client Email Address:
example@example.com
Parent Guardian Client Phone Number:
Please enter a valid phone number.
Include a copy of both sides of the client's insurance card. If you don't have one, answer the insurance questions below:

YesNo
Insurance Provider:
Insurance Phone Number:
Please enter a valid phone number.
Member ID:
Group Number:
Policy Holder Address:
Policy Holder DOB:

MonthDayYear
Date

Your Program Information
Your Program Name:*
Your Contact Name:*
Program Phone Number:*
Please enter a valid phone number.
Your Contact Email Address:*
example@example.com
Program City & State:
Program Level of Care:
Date of Admission:

MonthDayYear
Date
Expected Discharge Date:

MonthDayYear
Date
Admission Reason:
Client Information
Primary Diagnosis:
Additional Diagnoses:
Reason for Referral (include specific rationale for step-up/down):
Recommended Level of Care:
Preferred Location (if known):
Post-treatment living situation:
Is the client aware and supportive of the referral to SunCloudHealth?

YesNo
If the client is under 18 or has a legal guardian, do the parents/guardians agree with the referral to Suncloud Health?

YesNo
If the client is under 18 with divorced parents, both must agree to treatment, or you must provide proof of full custody for the parent giving consent. For adult clients with a guardian, please include legal guardianship paperwork.
Height:
Weight:
Temperature:
Pulse, Lying:
Pulse, Sitting:
Pulse, Standing:
BP, Lying:
BP, Sitting:
BP, Standing:
Weight on admission:
Recent weight change prior to admission?
Eating Disorder History/Notes: