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MBHP INTAKE AND REFERRAL FORM

Identified Client

Name (First, Middle Initial & Last)
Client Age:
Caretaker:

Please enter your contact info below:

Address # Street Name City, State, Zip	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Telephone
Evening #
Emergency

Medical Coverage:

Parent Child
Expiration Date Id Number

Gender	Male Female Transgender
Race\Ethnicity	Asian African-American Cape Verdean Caucasian Haitian Creole Hispanic\Latino Native American Biracial Mother’s Race Ethnicity Father’s Race Ethnicity Other (Please Name)
Children in Family	Mother’s Family: Girls Boys Father’s Family: Girls Boys
Housing Difficulties Present at referral:	Yes No If Yes, Type of difficulty:
Guardian	Mother Father Other (Describe below)

Type of Employment:

Domestic Violence	Mother Father Other (Describe below)	Any domestic violence in the past 6 months? (describe)
Does perpetrator live in the home?	Yes No	Other information on perpetrator
Current Hospitalization	Yes No	Reason Hospital
Past Hospitalization(s)	Yes No	Reason(s) # of Times Hospital

Ideations \ Gestures:

Suicide?	Yes	No
Homicide?	Yes	No
Other	Please Describe:

DSM-IV Diagnosis

Substance Abuse	Yes	No	History
Sex Abuse	Yes	No	History
Physical Abuse	Yes	No	History
Fire Setting	Yes	No	History
Running	Yes	No	History

Referred Child is in	Psychiatric Hospital Residential Facility Own Family Home Foster Care Group Home Other (describe below)
System Involvement	DSS DMR DYS DMH CHINS Other (describe below)
Intake Team

Client Strengths\Interests:

Additional Comments:

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