If Yes, where? Please rate severity of the pain: (low) (high)

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1 PHYSICAL HEALTH G01: How do you rate your current health? Excellent Good Fair Poor G02: Do you have or have you had any of the following: Acne (severe) Arthritis Asthma Autism/Aspergers Cancer Cardiovascular Disease Cerebral Palsy Chronic ear infections Chronic Insomnia Chronic Pain Diabetes Eczema (severe) Emphysema/COPD Epilepsy/Seizures YES NO DATE YES NO DATE Fibromyalgia Gastric or Intestinal Problems Head Trauma/Injury Hearing Problems Hepatitis High Blood Pressure Kidney Disease Liver Disease Migraines Speech Problems Thyroid Disease Tuberculosis Urinary/Bladder Infections Other: G16: Any past medical or surgical hospitalizations? Yes No If yes, please list: HOSPITAL DATE REASON DR. S NAME G03: Date of last physical exam: G04: Name of Primary Care Physician: G05: Are you currently pregnant? Yes No If Yes, specify due date, Obstetrician: G06: Height: Weight: G07: Any weight change over the last 4 months? Stable Loss Gain PAIN ASSESSMENT G11: Are you currently experiencing chronic pain? Yes No If Yes, where? Please rate severity of the pain: (low) (high) G12: If Yes, how frequently does this chronic pain interfere with your life activities? Never Rarely Less than 1x/wk Once per week 2-3 times per week Daily G13: Any difficulties with sleep? Yes No If Yes, please describe:

2 CONSUMER CRISIS CARE PLAN Emergency Contact: Phone #: Primary Care Physician: Dr. Phone #: Support Individual: Phone #: Pharmacy: Phone #: Psychiatric Emergency Program: Phone #: Insurance: Phone #: Sherman Hospital ER Insurance #: Psychiatrist: Phone #: Secondary Insurance: Insurance #: Phone #: F01-F04: Please list any medications (prescriptions, over-the-counter, herbal) or vitamins you are currently taking: MEDICATION DOSE TIME OF DAY TAKEN REASON F05: Do you have any adverse reactions or allergies to drugs or food? Yes No If yes, please describe: ALLERGY TYPE OF REACTION To be completed with staff: ACKNOWLEDGEMENT OF CRISIS CARE PLAN 1. I acknowledge with staff the purpose and development of a crisis care plan. 2. I accept a formatted crisis care plan to be utilized in the development of an individualized crisis care plan. Client Signature: Date: Staff Signature: Date: *(provide copy of this page for client s use)

3 AUTHORIZATION TO LEAVE PERSONAL HEALTH INFORMATION (PHI) BY ALTERNATE MEANS Current Mailing Address: I hereby authorize the Ecker Center for Mental Health to leave a voic or message as described below. I understand that this voic or message may contain my protected health information. (Please check all that apply) May leave detailed message on voic at home #: May leave detailed message on voic at work #: May leave detailed message on cellular phone #: May leave information with spouse (name): May leave information with other household member (name): May leave detailed message at a different location. (phone #): May leave detailed message at my address Do not leave any messages. Only speak with me directly at the following phone #: Please note that detailed information may include information about appointments, billing, referrals to other clinicians and/or lab tests. If a selection is not made above, Ecker Center staff will leave voic s or messages stating only their staff name, service provider and a call-back number. If the phone number is not active, information may be mailed to the address listed above. To be completed with staff: AUTHORIZATION TO LEAVE PHI BY ALTERNATE MEANS With my signature below, I acknowledge and understand that this information will be kept in my medical record and the above parameters will be abided by until revoked by me in writing. It is my responsibility to notify Ecker Center if I would like to change one or more of the telephone numbers listed above. Client (or legally authorized individual s signature) Date Staff witness signature Date

4 INSURANCE Private Insurance* Medicare * Medicaid * * Copy of insured s card must accompany this form. NOTE: It is very important that this form is completed with all requested information. If you need assistance in completing the necessary information, Ecker Center staff will gladly assist you. CLIENT INFORMATION PRIMARY INSURANCE COMPANY Name (as it appears on insurance card): Date of Birth: Address: Phone: Insurance Company Name: Claims Address: Phone: ID #: Group #: Group Name: INSURANCE POLICY HOLDER Name: FOR PRIMARY INSURANCE Date of Birth: Social Sec. #: Address: Phone: Employer Name: SECONDARY INSURANCE COMPANY (If Applicable) Insurance Company Name: Claims Address: Phone: ID #: Group #: Group Name: INSURANCE POLICY HOLDER Name: FOR SECONDARY INSURANCE Date of Birth: Social Sec. #: Address: Phone: Employer Name: With the information provided above and your written authorization below, we will file the necessary claim forms for reimbursement from your insurance carrier. AUTHORIZATION TO PAY TO PHYSICIAN/SUPPLIER: I hereby authorize the physician or supplier to receive the payment of medical benefits, if any, otherwise payable to me for the services described, not exceeding the reasonable and customary charge for these services. INSURED S SIGNATURE DATE INSURED S SOCIAL SECURITY #: RELATIONSHIP TO CLIENT: REVISED: 08/2013

5 TREATMENT Why are you seeking treatment? What are your desired outcomes for services or what do you hope to achieve from treatment? Please mark the level of you are having with the following symptoms or behaviors: Anxiety little Manic - like behavior little Depressive- like behavior little Antisocial behavior (such as deceitfulness, gang-activity, theft, vandalism, violent behaviors, abusive language) little Substance Abuse history little Hallucination little Delusions little

6 MENTAL HEALTH HISTORY C01: Any prior outpatient mental health treatment? Yes No If Yes, please list: FACILITY DATE REASON DR. S NAME C02: Any prior inpatient mental health treatment? Yes No If Yes, please list: HOSPITAL DATE REASON DR. S NAME C04: Have you taken psychiatric medications in the past? Yes No If Yes, please list: MEDICATION DOSE WAS IT HELPFUL? REASON FOR DISCONTINUING NUTRITION SCREEN Please circle the best answer: (0) (1) (2) How many meals do you eat per day? 3 or more 2 meals Less than 2 How many fruits, vegetables, or milk products do you eat per day? many few none On average, how many alcoholic drinks do you have per day? none or more Do you have tooth or mouth problems that make it hard to eat? no yes How many prescription medications do you take per day? none or more Has a medical condition or illness changed the way you eat? no yes Have you lost or gained 10 pounds or more in the last 4 months without wanting to? no yes Do you have a history of an eating disorder? no yes Do you have with: Swallowing Chewing Indigestion Heartburn Vomiting Diarrhea Constipation No with any of these Do you always have enough money to buy the food you need? Yes No Would you like information on food pantries in your area? Yes No Would you like information on where to apply for Link benefits (food stamps)? Yes No OFFICE USE ONLY: Nutritional Risk Score = If client scores 9 points or more, reports with eating or digestion, or reports nutritional issues, please refer to Primary Care Physician or local FQHC. Client was referred to Primary Care Physician local FQHC Other needed

7 SUBSTANCE USE D01: Are alcohol and/or drug use factors in seeking care at this time? D02/D04: How often do you use alcohol/drugs? How old were you when you started using alcohol/drugs regularly? Are you currently using the following substances: Yes No/ Opiates (pain pills, heroine, codeine) If yes, list what is used, amount, & frequency per week: Yes No/ Stimulants (Methamphetamine/amphetamines, nicotine, caffeine, cocaine, crack) If yes, list what is used, amount, & frequency per week: Yes No/ Inhalants (spray paint, plastic cement, rubber cement, typewriter-correction fluid, gasoline, nitrites, nitrous oxide) If yes, list what is used, amount, & frequency per week: Yes No/ Depressants (glutethimide (Doriden) and methaqualone (Quaalude); the major tranquilizers (phenothiazines) and minor tranquilizers (benzodiazepines) If yes, list what is used, amount, & frequency per week: Yes No/ Marijuana If yes, list what is used, amount, & frequency per week: Yes No/ Alcohol If yes, list what is used, amount, & frequency per week: Yes No/ Abuse of other Prescription Medication If yes, list what is used, amount, & frequency per week: Yes No/ Designer drugs (ectasy, K-2,spice, synthetic marijuana) or hallucinogens (LSD,mushrooms) If yes, list what is used, amount, & frequency per week: Has drinking/using drugs created problems for you with your family, friends or job? Yes No Have you ever been injured because of drinking/using drugs? Yes No Have you recently (past six months) been arrested because of drinking/using drugs? Yes No D03/D05: Have you ever had treatment for alcohol/drug problems or alcohol-related/drug-related illness? Yes No If yes, list treatment programs and dates of treatment: LOCATION DATE REASON OUTCOME 1. Have you ever been unable to completed a task or function because of alcohol- or drug-related illness? Yes No 2. Have you noticed a change in the amount of alcohol/drugs it takes to get the effect you desire? Yes No 3. Do you feel discomfort when you stop drinking or using drugs? Yes No 4. When drinking/using drugs, have you ever experienced a period of time you don t remember? Yes No 5. Have you ever felt you should Cut down on your drinking or drug use? Yes No 6. Have people Annoyed you by criticizing your drinking or drug use? Yes No 7. Have you ever felt bad or Guilty about your drinking or drug use? Yes No 8. Have you had an Eye opener first thing in the morning to steady nerves or get rid of a hangover? Yes No OFFICE USE ONLY If yes was indicated on any question from 1 to 8, there is evidence that a substance use disorder may be present. A referral needs to be made to an outside substance abuse agency. Referral made to substance abuse agency: Yes No

8 EDUCATION E01: Are you currently enrolled in an education or training program? Yes No VOCATION If Yes: E02: School type: High School GED/Night School Community College Technichal Training Program 4-year College Graduate Program E03: Current grades: Above Average Average Below Average E04: Satisfaction level with current program: Highly Satisfied Satisfied Not Satisfied If No: Last Grade Completed: Are you satisfied with your level of education? E08: Are you currently employed? Yes No LEGAL If Yes: E11: Current Occupation: E12: Hours per week: 3-15 hrs/wk hrs/wk 31+ hrs/wk E13: Length of time with this employer: 1-3 months 3-6 months 6 months-1 year 1-3 years 3-6 years more than 6 years E14: Relationship with employer: Good Fair Poor E15: Relationship with coworkers: Good Fair Poor E16: Satisfaction level with employment: Highly Satisfied Satisfied Not Satisfied E20: Do you have a legal guardian? Yes No E21: Are you currently involved with the court system? Yes No If Yes, please describe: E22: Any past involvement with the court system? Yes No If Yes, please describe: E24: Do you have a Representative Payee? Yes No E25: Do you have a Declaration of Mental Health Care? Yes No E26: Do you have a Power of Attorney for Health Care? Yes No HOUSING AND INCOME H03: Who lives in your current household? H09: Current housing type: No Current Residence Apartment Condominium Mobile Home Single-Family Home Townhome H10: Satisfaction with housing: Highly Satisfied Satisfied Not Satisfied Highly Dissatisfied H11: Home Atmosphere: Comfortable/Supportive Neutral Uncomfortable/Conflict-filled Chaotic/Disorganized Abusive/Destructive No Current Home H12: Household Income: Sufficient Mildly Insufficient Insufficient Grossly Insufficient Unsure

9 **If you are uninsured and/or you would like to talk with a nurse about receiving help to obtain your medications, please complete the following: PATIENT ASSISTANCE REFERRAL FORM Client s phone number: Current Medications: MEDICATION DOSE TIME OF DAY TAKEN REASON Insurance Status: Private Insurance Medicare Medicaid Other: I understand that I may be required to provide additional proof of income to receive assistance from this program. Staff Signature Client Signature Date Date NOTE: To all staff, please review with client and then forward this page to Nancy Zavala 08/2013