FACE SHEET Identifying/Background Information (AFFILIATED WITH BEHAVIORAL COUNSELING SERVICES, LLC) ...

FACE SHEET - Identifying/Background Information

ACHIEVING BETTER COPING SKILLS LLC R6-5-7428(A)
LOCATION
YOUTH FULL NAME
PARTICIPANT ID#
Mercy Care DCS CHP Member ID No.
previously known as Participant ID (PI No.) or CMDP
DOB

MonthDayYear
Date of Entry

MonthDayYear
SOURCE OF REFERRAL
GENDER
Race/Ethnicity
Religious Preference
Height
Weight
Hair Color
Eye Color
YOUTH BIRTHPLACE
SOCIAL SECURITY NUMBER
DCS Specialist Information
AZDCS Specialist Name

First NameLast Name
PHONE
FAX
ADDRESS
EMAIL
example@example.com
EMERGENCY PLACEMENT
CHANGE OF CUSTODY/ NTP (COPY PROVIDED)
SCHOOL RECORDS PROVIDED
NAME OF SCHOOL ATTENDED
PROBATION/PAROLE INFORMATION
ON PROBATION
ON PAROLE
REASON FOR PROBATION OR PAROLE
PROBATION/PAROLE OFFICER"S NAME
PHONE
FAX
EMAIL
COMMUNITY HOURS TO COMPLETE
NUMBER OF HOURS
YOUTH NAME (PAGE 2 OF FACE SHEET)
MEDICAL INFORMATION
PSYCHOTROPIC MEDS
PRESCRIPTION MEDS
MEDICAL CONDITION
DOES HE USE AN INHALER?
WAS AN INHALER PROVIDED IF NEEDED?
ALLERGIC TO THE FOLLOWING?

Other
PHYSICAL PROVIDED

Yes, Date of Exam
#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

MonthDayYear
DISTINGUISHING MARKS, SCARS, TATTOOS
DIAGNOSED OR STATED ALLERGIES
IS YOUTH TITLE XIX CERTIFIED?

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

Other
PART OF A SIBLING GROUP
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.
COMPLETED BY (STAFF NAME)
Staff Signature
Should be Empty:

FACE SHEET - Identifying/Background Information