ADMISSION AND INTAKE
ACHIEVING BETTER COPING SKILLS, LLC)R6-5-7428(A), R6-5-7438(D-E), R6-5-7444(C)
Facility Admitting Youth
*
Please Select
SHOULDER'S HOUSE
Youth Name
*
First Name
Last Name
Participant ID#
*
CMDP #
*
DOB
*
-
Month
-
Day
Year
Date Picker Icon
Birthplace
*
Date of Entry
*
-
Month
-
Day
Year
Date Picker Icon
Source of Referral
*
AZDCS
Other
AZDCS Specialist Name
First Name
Last Name
DCS Specialist Email
example@example.com
DCS Specialist Phone Number
Please enter a valid phone number.
DCS Specialist Fax Number
NOTICE TO PROVIDER INFORMATION
Documentation of current custody and legal guardianship?
Yes
No
Written agreement with placing agency, court order or parent?
Yes
No
Written consent authorizing routine Medical and Dental procedures?
Yes
No
INTAKE ASSESSMENT
Social History Assessment
Educational History Assessment
Legal Assessment
Family History Assessment
Behavioral History Assessment
Psychological History Assessment
Developmental History Assessment
CONTACT SHEET INFORMATION
First Allowed Contact and Phone Number
Relationship of First Contact
Please Select
Mother
Father
Brother
Sister
Grandmother
Grandfather
Aunt
Uncle
Other
Second Allowed Contact and Phone Number
Relationship of Second Contact
Please Select
Mother
Father
Brother
Sister
Grandmother
Grandfather
Aunt
Uncle
Other
Other Allowed Contacts (List name, number/email, relationship)
NO CONTACT LIST (List Names and Relationship)
COMPLETED BY (STAFF NAME)
*
Staff Signature
*
Submit
Should be Empty: