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Date______________
Name (First and Last)
Client Gender
If female, maiden name required
Mailing Address: PO Box
City, State, Zip
Physical Address: Street, Apartment
City, State, Zip
Phone Number(s)
Emergency Contact w/phone number
Date of Birth (mm/dd/yyyy)
Social Security Number
Medicaid ID Number
________________________________________________
_ Female Male Other
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
_
Demographics
Race(s): Check all that apply
American Indian Asian Black/African American Caucasian Native Hawaiian Pacific Islander Other Unknown
Alaska Native: Aleut Athabascan Haida Inupiat Tlingit Tsimshian Yupik Other Alaska Native
Ethnicity: Check one
Not Spanish/Hispanic/Latino Chicano Cuban Hispanic Mexican American Puerto Rican Spanish/Hispanic/Latino Unknown
Special Needs: Check all that apply
None No Response Dev Disabled Major Difficulty in Ambulating Moderate to Severe Medical
Problems Severe Hearing Loss or Deaf Traumatic Brain Injury Visual Impairment or Blind Other Unknown
Education: Check one response
If K-11, how many years completed:_________
GED High School Diploma Vocational Training Special Ed Classes Bachelors degree Graduate work (no degree) Master’s degree Doctorate degree Post Secondary 1 yr Post Secondary 2 yrs Post Secondary 3 yr Post Secondary 4+ yrs (no degree) Other Unknown
English Fluency: Check one Excellent Good Moderate Poor Not at all No responseVeteran Status: Check one Never in Military Reserves/Nat. Guard- combat Reserves- no combat Military Dependent Active duty combat Active duty no combat Retired from military Veteran other eras Vietnam vet combat Vietnam vet no combat Unknown
CRNA BHS Intake 1/4
Behavioral Health Services Intake Admission
Intake Information
Intake Staff: ___________________________________________ Date: ____________________________
Initial Contact: Check one
Phone Drop In (Orientation) Hospital/On Call Intervention
Community Service Patrol By Appointment Other
Village: ______________________________________________________
Source of Referral: Check one
ASAP Federal Probation Office of Children’s Services Department of Corrections/Jail Correctional Agency (Probation or Parole) Court – Civil Proceedings Court – Criminal Proceedings Individual/Self Referral Crisis/Respite Care Alaska Native Hospital Detox or Residential Program
API Assisted Living Facility Attorney Developmental Disabilities Residential Program Developmental Disabilities Program Drug Program, Employer (EAP) Halfway House Nursing Home Other Mental Health (not including psychiatrist) Other
Pregnant:___ yes ___no ___unknown If yes, projected due date: __ __/ __ __/ __ __
Injection Drug User: ___ yes ___no ___unknown
Tobacco Use: ____ none ____ cigarettes ____ cigar/pipe ____ smokeless ____ combination
# of Arrests within the last 30 days: ______
If attending school, # of absences within the last 30 days: ______
Presenting Problem(s) Why are you seeking services? __________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Special Initiative: Check all that apply
None Therapeutic Courts Women w/Children Acquired Brain Disorders Adult- Organic Disorder w/out SED Adult- Severe & Persistent Mental Illness Adult- Severe Emotional Disturbance
Fetal Alcohol Syndrome HIV Methadone Persistent & Disabling Personality Disorder Psychiatric Emergency Services Traumatic Brain Injury
CRNA BHS Intake 2/4
Admission Type: ___First Admission ___Readmission
Are you the person seeking services?: Yes No
# of Prior Substance Abuse Treatment Admissions: _______
# of Non-Treatment Substance Abuse Related Hospitalizations in Past 6 Months: _______
# of Prior Mental Health Treatment Admissions: _______
# of Prior Mental Health Hospitalizations: _______
Current Health Status: ___ Poor ___ Fair ___Good ___Very Good ___Excellent
Pharmacotherapy Planned: ___ Yes or ___No
On Psychotropic Medication: ___Yes or ___No
Financial/ Household Information
Employment Status: Check One
Disabled Employed Full Time Employed Part Time Homemaker Armed Forces Resident/Inmate Retired Seasonal Employee/in season Seasonal Employee/out season Student Unemployed/Not seeking work Unemployed/Subsistence Unemployed/Looking for work Not in Labor Force/Other Other
Primary Income Source: Check one
None Alaska Native Corp Dividends Alimony Alaska PFD Employment Public Assistance Parent’s Income Retirement/Disability Pension Social Security Disability Spouse/Significant Income SSI Unemployment Compensation Other Unknown
Expected Payment Source: Check One
Blue Cross/Blue Shield CIGNA Medicaid Client Self Pay Other
Insurance Type: Check One
None Private Insurance VA insurance Other Unknown
Occupation: Check One
Crafts/Operatives Farm Owner/Laborer Laborer (not farm) Professional/Managerial Sales Services/Household None Unknown
Household Income: Check One
0-$999 $1,000-4,999 $5,000-9,999 $10,000-19,999 $20,000-29,999
$30,000-39,999 $40,000-49,999 $50,000 and over No Response Unknown
CRNA BHS Intake 3/4
Who is responsible for payment of services? Self / Other: ____________________________________
Are you a compacting village member? Yes / No If yes which village: ______________________
Please submit your insurance information (Medicaid ID, insurance card, etc.) If you do not submit this information you may be charged for services.
Consent and Authorization
I consent to receive services provided by Copper River Native Association Behavioral Health Services. _______________________________________ ______________ Client Signature Date
_______________________________________ ______________ Guardian Signature (if applicable) Date
I authorize CRNA Behavioral Health Services to release to the insurance carrier such information as necessary for the completion of my claim. This information will generally be limited to diagnosis, dates of service, and person(s) rendering services.
_______________________________________ ______________ Client Signature Date
_______________________________________ ______________ Guardian Signature (if applicable) Date
CRNA BHS Intake 4/4
Household Composition: Check One
Lives alone Lives with adolescents Lives with children Lives with non-relatives Lives with relatives Lives with significant other Other No response
Living Arrangement: Check One
Private Residence without supportive services Private residence with supportive services Homeless Correction/Detention Facility Crisis Residence Halfway House Hospital for Non-psychiatric purposes Hospital for psychiatric purposes Shelter Residential Treatment Nursing home Other Unknown
Marital Status: Check one
Cohabitating Divorced Married Never Married-single Separated Widowed Unknown
Living in Home: Answer all
Number of people living with client: #____
Number of children in household: #____
Number of children in Residential Treatment Setting: #____
Number of children in Residential Tx Setting receiving services: #____
Guarantor Name (First and Last)
Relationship to Patient
Mailing Address: PO Box
City, State, Zip
Physical Address: Street, Apartment
City, State, Zip
Phone Number(s)
Date of Birth (mm/dd/yyyy)
Social Security Number
__________________________________________________
_
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Race(s): Check all that apply
American Indian Asian Black/African American Caucasian Native Hawaiian Pacific Islander Other Unknown
Alaska Native: Blood Quantum: _______ Aleut Athabascan Haida Inupiat Tlingit Tsimshian Yupik Other Alaska Native
Ethnicity: Check one
Not Spanish/Hispanic/Latino Chicano Cuban Hispanic Mexican American Puerto Rican Spanish/Hispanic/Latino Unknown
Employment Status: Full Time Part Time Student Disabled Unemployed
If employed, list current employer(s): __________________________________
____________________________________________________________________
If a student, list school(s) currently attended: ____________________________
____________________________________________________________________
Please submit your insurance information (Medicaid ID, insurance card, etc.) If you do not submit this information you may be charged for services.
I authorize CRNA Behavioral Health Services to release to the insurance carrier such information as necessary for the completion of my claim. This information will generally be limited to diagnosis, dates of service, and person(s) rendering services.
_______________________________________ ______________ Client Signature Date
_______________________________________ ______________ Guardian Signature (if applicable) Date
CRNA BHS Guarantor 1/1
Behavioral Health Services Guarantor (responsible payer/party) Information
MEDICAL SCREENING FORM Perform with Bio-Psycho-Social Assessment
(Form Physician Approved- Required by Substance Abuse Standards, JAHCO & CARF) Client Name: Client #:
Current Medical Conditions:
Client Signature Date
Do You Have or Have You Had: (Check & describe all that apply to you) X Type Description Major illnesses Severe fatigue after little activity Feeling tired all the time Unusual swelling or lumps Heart problems in self or family Blurred vision or difficulty seeing Shortness of breath with exercise Buzzing or ringing in your ears Swollen feet or ankles Frequent colds or coughs Severe headaches Problems with your sleep or rest Bleeding gums or teeth problems Aching joints or muscles Constipation or diarrhea Unusual thirst or hunger Major injures/surgeries Recent changes in your weight Allergies (foods, drugs, or others) Any problem with urination Blood in your stool or urine Appetite/ability to eat changes Diabetes
Date of last physical exam: Doctor: Date of last dental visit: Dentist: Date of last vision exam: Eye Doctor:
For Females Only - Do You Have or Have You Had: (Check and describe all that apply to you) Any unusual vaginal discharge: Regular periods: Y N Excessive menstrual bleeding: Are your pregnant: Y N
Do you use birth control: Y N Type: Currently on hormone therapy: Y N When was your last pap smear: When was your last pregnancy: ___________
ALASKA SCREENING TOOL
Client Name: __________________________________________ Client Number: ____________________________
Staff Name: ____________________________________________________ Date: ___________________________
Info received from: (include relationship to client) _____________________________________________________
Please answer these questions to make sure your needs are identified. Your answers are important to help us serve you better. If you are filling this out for someone else, please answer from their view. Parents or guardians usually complete the survey on behalf of children under age 13.
SECTION I – Please estimate the number of days in the last 2 weeks (enter a number from 0-14 days): 0-14 days
1. Over the last two weeks, how many days have you felt little interest or pleasure in doing things?......______ 2. How many days have you felt down, depressed or hopeless?...............................................................______ 3. Had trouble falling asleep or staying asleep or sleeping too much?......................................................______ 4. Felt tired or had little energy?................................................................................................................______ 5. Had a poor appetite or ate too much?...................................................................................................______ 6. Felt bad about yourself or that you were a failure or had let yourself or your family down?...............______ 7. Had trouble concentrating on things, such as reading the newspaper or watching TV?.......................______ 8. Moved or spoken so slowly that other people could have noticed?.....................................................______ 9. Been so fidgety or restless that you were moving around a lot more than usual?................................______ 10. Remembered things that were extremely unpleasant?.........................................................................______ 11. Were barely able to control your anger?...............................................................................................______ 12. Felt numb, detached, or disconnected?.................................................................................................______ 13. Felt distant or cut off from other people?.............................................................................................______
SECTION II – Please check the answer to the following questions based on your lifetime. 14. I have lived where I often or very often felt like I didn’t have enough to eat, had to wear
dirty clothes, or was not safe............................................................................................ Yes No 15. I have lived with someone who was a problem drinker or alcoholic, or who used street
drugs................................................................................................................................. Yes No 16. I have lived with someone who was seriously depressed or seriously mentally ill.......... Yes No 17. I have lived with someone who attempted suicide or completed suicide....................... Yes No 18. I have lived with someone who was sent to prison.......................................................... Yes No 19. I, or a close family member, was placed in foster care..................................................... Yes No 20. I have lived with someone while they were physically mistreated or seriously
threatened........................................................................................................................ Yes No 21. I have been physically mistreated or seriously threatened.............................................. Yes No
a. If you answered “Yes”, did this involve your intimate partner (spouse, girlfriend, orboyfriend)?....................................................................................................................... Yes No
DHSS/Division of Behavioral Health Performance Management System Version Date: June 21, 2010
ALASKA SCREENING TOOL SECTION III – Please answer the following questions based on your lifetime. (D/N = Don’t Know)
22. I have had a blow to the head that was severe enough to make me lose consciousness.. Yes No D/N
23. I have had a blow to the head that was severe enough to cause a concussion……………… Yes No D/N If you answered “Yes” to 22 or 23, please answer a-c:
a. Did you receive treatment for the head injury?...................................................... Yes No
b. After the head injury, was there a permanent change in anything?....................... Yes No D/N c. Did you receive treatment for anything that changed?.......................................... Yes No
24. Did your mother ever consume alcohol?.......................................................................... Yes No D/N a. If Yes, did she continue to drink during her pregnancy with you?.......................... Yes No D/N
SECTION IV – Please answer the following questions based on the past 12 months.
25. Have you had a major life change like death of a loved one, moving, or loss of a job?...... Yes No
26. Do you sometimes feel afraid, panicky, nervous or scared?............................................... Yes No 27. Do you often find yourself in situations where your heart pounds and you feel anxious
and want to get away?........................................................................................................ Yes No
28. Have you tried to hurt yourself or commit suicide?........................................................... Yes No
29. Have you destroyed property or set a fire that caused damage?...................................... Yes No
30. Have you physically harmed or threatened to harm an animal or person on purpose?.... Yes No
31. Do you ever hear voices or see things that other people tell you they don’t see or hear?. Yes No
32. Do you think people are out to get you and you have to watch your step?....................... Yes No
SECTION V – Please answer the following questions based on the past 12 months.
33. Have you gotten into trouble at home, at school, or in the community, because of using
alcohol, drugs, or inhalants?............................................................................................. Yes No
34. Have you missed school or work because of using alcohol, drugs, or inhalants?.............. Yes No
35. In the past year have you ever had 6 or more drinks at any one time?............................. Yes No 36. Does it make you angry if someone tells you that you drink or use drugs, or inhalants
too much?........................................................................................................................... Yes No
37. Do you think you might have a problem with alcohol, drug or inhalant use?.................... Yes No
THANK YOU for providing this information! Your answers are important to help us serve you better.
DHSS/Division of Behavioral Health Performance Management System Version Date: June 21, 2010
Infectious Disease Risk Assessment
The following questions are necessary to assess your risk for infectious diseases. You are not required to answer these questions to participate in an assessment/treatment and client confidentiality laws protect all answers.
Client Name: __________________________________________ Client #: ___________
Infectious Disease Risk Yes No ?
Have you seen a health care provider in the past three months
Do you or have you lived on the street or in a shelter
Have you ever been in jail/prison/juvenile detention
Have you ever been in a long-term care facility (mental health hosp, nursing home, rehab)
In the past 3 months, have you traveled outside the US (where:____________________)
Are you a combat veteran
In the past year, have you had a tattoo, body piercing, acupuncture, or contact with blood
Where were you born
How long have you been in the US
Have you lived with anyone diagnosed with TB in the past year
Have you ever been treated for TB
Have you ever been told you have Hepatitis A
Have you ever been told you have Hepatitis B
Have you ever been told you have Hepatitis C
Have you ever used needles to shoot drugs
Have you ever shared needles or syringes to inject drugs
Have you ever had a job where you were at risk for needle sticks or blood contact
In the past year, have you or anyone you had sex with have an STD or Hepatitis
In the past 30 days have you had any of these symptoms lasting more than 2 wks
Nausea
Fever
Drenching night sweats that were so bad you had to change clothes or bed sheets
Productive cough
Coughing up blood
Shortness of breath
Lumps or swollen glands in the neck or armpits
Loss of weight without trying to
Diarrhea lasting more than a week
Brown tinged urine
Women: Missed periods for last two months
Extreme fatigue
Jaundice or yellow eyes
HIV/AIDS/Hepatitis C Risk Yes No ?
Did you receive a blood transfusion before 1992
Have you received blood products produced before 1987 for clotting problems
Was your birth mother infected by Hepatitis C during the time of your birth
Have you been or are you currently on long-term kidney dialysis
Have you had unprotected sex with someone who has the blood disease hemophilia
Have you had unprotected sex with a person who injects drugs
Have you had unprotected sex with a man who has sex with other men
Have you had sex in exchange for money or drugs in order to survive
Have you had unprotected sex with more than one partner in the past 6 months
Have you had sex or shared needles with a person who has AIDS, HIV+, or Hep C +
Have you ever injected drugs, even once
Have you ever been pricked by a needle that may have been infected with HIV or Hep C
Have you ever had a blood test for HIV
If no, would you like to be tested
If yes, was it within the last six months
Have you ever had a blood test for Hepatitis C
If no, would you like to be tested
If yes, was it within the last six months
How would you judge your own risk for being infected with HIV (Please check one)
I know I am infected
I think I am at high risk
I think I am at low risk
I think I am at NO risk
I am not sure what my risk is
How would you judge your own risk for being infected with Hepatitis C (Please check one)
I know I am infected
I think I am at high risk
I think I am at low risk
I think I am at NO risk
I am not sure what my risk is
Client Signature Date
Name: __________________________________________ Date: __________________
Everyone has strengths that they can use to reach their goals. Some of my/my child’s strengths are:
a good sense of humor a driver’s license/vehicle supportive family/friends a good home a strong work ethic strong morals/cultural values/faith patience a good listener education/vocational training caring about others
Explanation/Other: _________________________________________________________________
_________________________________________________________________________________
Some things I may need to increase the quality of my/my child’s life include:
transportation improved physical/mental health financial assistance education or employment opportunities a safe/clean home improved social skills social or family supports a better ability to manage symptoms
Explanation/Other: _________________________________________________________________
_________________________________________________________________________________
Some of my/my child’s abilities, skills, or talents include:
cultural/traditional/subsistence skills school/academic ability artistic/musical talent writing skills athletic/sports ability social/people skills
Explanation/Other: _________________________________________________________________
_________________________________________________________________________________
My preferences regarding services at CRNA BHS include:
Specific appointment days/times A specific type of service
Explanation/Other: _________________________________________________________________
__________________________________________________________________________________________________
Behavioral Health Services Strengths, Needs, Abilities, Preferences (SNAP)
Behavioral Health Services
Consent for services I, ______________________________________________________ voluntarily consent to receive services from Behavioral Health Services. Initial all when received: __________ I have received a copy of CRNA Patient Rights and Responsibilities. __________ I have received a copy of CRNA Grievance Procedure Policy. __________ I have received a copy of CRNA Privacy Practices (HIPAA/CFR 42). __________ I have received a copy of CRNA Billing Practices/Mandatory Legal Fees. __________ I have received a copy of CRNA Sliding Fee Scale. __________ I have received a copy of CRNA Program Policies. __________ I have received a walk-through of relevant facilities. Safety equipment was pointed out to me and safety drills were explained (if applicable). My rights and responsibilities as a client, grievance policy and procedures, confidentiality practices, and all available services have been explained to me in an understandable format, and I understand and agree with them. The sliding fee schedule and billing practices have been explained to me and I understand and acknowledge that the amount agreed upon is reasonable and just. I further acknowledge that I agree to this of my own free will. I understand this statement may be altered any time my circumstances change significantly. I agree to notify this agency of any change in my income, resources or other circumstances pertinent to this statement as soon as possible. My consent to receive services does not waive my legal rights as recognized under Alaska and federal law. ____________________________________ ___________ Signature of Client Date ____________________________________ ___________ Signature of Parent/Guardian (If Applicable) Date ____________________________________ ___________ Signature of Witness Date
CRNA BHS Consent for Services 1/1