Legal History (DOC, jail, mental health commitments, chemical dependency commitments): Is person on a Court Order or LRA? NAME OF CORRECTIONS / PAROLE OFFICER TELEPHONE NUMBER Yes No Previous Mental Health Involvement: MEDICATION DOSAGE AMOUNT Describe all known allergies: Describe all Known Physical and Medical Problems: Describe all Known Treatments: CURRENT GENERAL PHYSICIAN TELEPHONE NUMBER CURRENT MH PRESCRIBER TELEPHONE NUMBER Is the person ambulatory? Yes No Does the person use a prosthetic device? Yes No If yes, describe: Is the person willing to take medications as prescribed? Yes No Date of last medication review: Known Appointments Scheduled (who / where / when): Treatment Plan / Goals for the Person: Client Financial Resource Information:
Legal History (DOC, jail, mental health commitments, chemical dependency commitments): Is person on a Court Order or LRA? Yes No NAME OF CORRECTIONS / PAROLE OFFICER TELEPHONE NUMBER Previous Mental Health Involvement: MEDICATION DOSAGE AMOUNT Describe all known allergies: Describe all Known Physical and Medical Problems: Describe all Known Treatments: CURRENT GENERAL PHYSICIAN TELEPHONE NUMBER CURRENT MH PRESCRIBER TELEPHONE NUMBER Is the person ambulatory? Yes No Does the person use a prosthetic device? Yes No If yes, describe: Is the person willing to take medications as prescribed? Yes No Date of last medication review: Known Appointments Scheduled (who / where / when): Treatment Plan / Goals for the Person: Client Financial Resource Information: