FACE SHEET - Identifying/Background Information
ACHIEVING BETTER COPING SKILLS LLC R6-5-7428(A)
LOCATION
Please Select
SHOULDER'S HOUSE
YOUTH FULL NAME
PARTICIPANT ID#
Mercy Care DCS CHP Member ID No.
previously known as Participant ID (PI No.) or CMDP
DOB
-
Month
-
Day
Year
Date Picker Icon
Date of Entry
-
Month
-
Day
Year
Date Picker Icon
SOURCE OF REFERRAL
GENDER
Male
Race/Ethnicity
Religious Preference
Height
Weight
Hair Color
Eye Color
YOUTH BIRTHPLACE
SOCIAL SECURITY NUMBER
DCS Specialist Information
AZDCS Specialist Name
First Name
Last Name
PHONE
FAX
ADDRESS
EMAIL
example@example.com
EMERGENCY PLACEMENT
YES
NO
CHANGE OF CUSTODY/ NTP (COPY PROVIDED)
YES
NO
SCHOOL RECORDS PROVIDED
YES
NO
NAME OF SCHOOL ATTENDED
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
YOUTH NAME (PAGE 2 OF FACE SHEET)
MEDICAL INFORMATION
PSYCHOTROPIC MEDS
YES
NO
PRESCRIPTION MEDS
YES
NO
MEDICAL CONDITION
GOOD
FAIR
POOR
DOES HE USE AN INHALER?
YES
NO
WAS AN INHALER PROVIDED IF NEEDED?
YES
NO
ALLERGIC TO THE FOLLOWING?
PENICILLIN
TOMATOES
PEANUTS
SHELLFISH
Other
PHYSICAL PROVIDED
NO
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
-
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
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.
COMPLETED BY (STAFF NAME)
*
Staff Signature
*
Submit
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