THE RICKY WRIGHT PRE-SCREEN INTAKE FORM

Date:_____________

Name of Referred:______________________________________________________

Date of Birth:__________

Address:________________________________

City:____________________

State:_____

Zip code:_____________

SS#:____________________ 

Sex:____

Parent/Legal Guardian:____________________________________________

Home Telephone: ( )__________________ Work #: ( )_________________

Name of person making referral:_____________________________________

Telephone #: ( )___________________

Referring Agency:________________________________________

DSS Involvement:______________________________

DSS Caseworker:_________________________

Tel. #: ( )___________________

Reason Referred for Inpatient Treatment: ______________________________________________

Psychiatric Problems: ______________________________________________

Medications: ______________________________________________

History of Violence: ______________________________________________

Suicide Attempts: ______________________________________________

Prior Counseling/Treatment Facility: _________________________________________

Type Tx: Outpatient _____ IOP _____ Inpatient _____

Dates of Counseling/Treatment: _____________________________________________

Payment Information

Medicaid #: __________________________________

Insurance Company: ____________________________________________________

Policy Holder Name: ______________________________________________

Policy Holder's SS #: ___________________________________

Policy Holder's Birthdate: __________________ Group #: ____________________

Policy Holder's Employer: ______________________________________________

Benefits Tel. #: ( ) _________________________

Precertification Tel. #: ( ) _________________________

Secondary Insurance: ______________________________________________

Total Family Income: ____________
per week / every other week / per month / per year

Total number of people living in house: ________

School Information

Name of School currently attending or last school attended: _______________________

Please circle one:
still attending
expelled
suspended
dropped out
Date last attended: _______________________________

To better assist "The Ricky Wright" Facility staff in determining if this adolescent meets Inpatient Criteria, the following information should be faxed or mailed to Ricky Wright or Carol Loving Wright at the address listed on the front of this document.

Most recent Clinical Assessment

Most recent Psychiatric/Psychological

Evaluation Last R&E Report

Copy of Medicaid/Insurance Card/W-2 form or Paycheck