ACHIEVING
BETTER COPING SKILLS, LLC
FACE SHEET
Identifying/Background Information
R6-5-7428(A)
LOCATION
*
Please Select
ASHER HOUSE
YOUTH FULL NAME
*
CMDP #
DATE OF ADMISSION
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Month
-
Day
Year
Date Picker Icon
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
SOURCE OF REFERRAL
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GENDER
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Male
Race/Ethnicity
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Religious Preference
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Height
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PARTICIPANT ID#
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Weight
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Hair Color
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Eye Color
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YOUTH BIRTHPLACE
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SOCIAL SECURITY NUMBER
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NAME OF SCHOOL ATTENDED
CASE MANAGER INFORMATION
CPS/ADCS CASE MANAGER NAME
PHONE
FAX
ADDRESS
EMAIL
example@example.com
EMERGENCY PLACEMENT
*
YES
NO
SCHOOL RECORDS PROVIDED
YES
NO
CHANGE OF CUSTODY/ NTP (COPY PROVIDED)
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YES
NO
PROBATION/PAROLE INFORMATION
ON PROBATION
*
YES
NO
ON PAROLE
*
YES
NO
REASON FOR PROBATION OR PAROLE
*
PROBATION/PAROLE OFFICER"S NAME
PHONE
FAX
EMAIL
COMMUNITY HOURS TO COMPLETE
YES
NO
NUMBER OF HOURS
MEDICAL INFORMATION
PSYCHOTROPIC MEDS
*
YES
NO
PRESCRIPTION MEDS
*
YES
NO
MEDICAL CONDITION
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GOOD
FAIR
POOR
DOES HE USE AN INHALER?
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YES
NO
WAS AN INHALER PROVIDED IF NEEDED?
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YES
NO
ALLERGIC TO THE FOLLOWING?
PENICILLIN
TOMATOES
PEANUTS
SHELLFISH
Other
PHYSICAL PROVIDED
*
YES
NO
#1 MEDICATION NAME
MG AMOUNT
LABEL INSTRUCTIONS
#2 MEDICATION NAME
MG AMOUNT
LABEL INSTRUCTIONS
#3 MEDICATION NAME
MG AMOUNT
LABEL INSTRUCTIONS
#4 MEDICATION NAME
MG AMOUNT
LABEL INSTRUCTIONS
PSYCHIATRIST NAME
PHONE
FAX
EMAIL
ADDRESS
ANY SURGERIES, SPECIAL NEEDS OR CONDITIONS
Date of Surgery
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Month
-
Day
Year
Date Picker Icon
DISTINGUISHING MARKS, SCARS, TATTOOS
DIAGNOSED OR STATED ALLERGIES
IS YOUTH TITLE XIX CERTIFIED?
NO
YES, TITLE #
FAMILY INFORMATION
FATHER"S NAME
FATHER"S ADDRESS
FATHER"S PHONE
FATHER"S EMAIL
MOTHER"S NAME
MOTHER"S ADDRESS
MOTHER"S PHONE
MOTHER"S EMAIL
MARITAL STATUS OF YOUTH'S PARENTS
*
Married
Divorced
Separated
Together, but Not Married
Never Married
Other
PART OF A SIBLING GROUP
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YES
NO
If not living with parent(s), list the Name, Address, Phone Numbers, Company Name if applicable, and relationship of person child was living with prior to admission.
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COMPLETED BY (STAFF NAME)
*
Signature
*
Submit
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