Youth Pre-Evaluation Screening Date: Time In: Time Out: Interview Location: Individuals Present: Pending Felony Charges: Yes No Interpretative Aids/Assisted Devices: ☐ ☐ Case Number: CMHC Region: Voluntary CSU Admission Sought : Yes No In the court of County ☐ ☐ Mobile Crisis Involvement : Yes No ☐ ☐ Information from this interview will be reported on a standardized form and submitted to the chancery court and civil commitment examiners. You have the right to refuse to participate. Other sources of information including a review of your legal medical records and interviews with family member and the affiant requesting commitment will be included in this report. Respondent Demographics Name: DOB: Age: Gender: Race: Social Sec #: Medicaid #: Medicare#: Home Address: Phone Number: Does the respondent have a legal guardian or conservator: Yes No ☐ ☐ Guardian/Conservator Contact Information Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other Affiant Demographics Affiant Name: Relation of Respondent: Number: Home Address: Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other Respondent Psychosocial Information Current Living: Current Grade in School: Name of School: History of IEP or 504C: Yes No Date of most recent IEP or 504C: ☐ ☐ Juvenile Justice Involvement: Yes No ☐ ☐ Describe Source of Information: Review ☐Respondent ☐Affiant ☐Other Psychiatric History Current Psychotropic Medications: Dosage & Date/Time Last Taken: Is the medication helpful or problematic: Psychiatric Hospitalizations: Outpatient Treatments: Locations/Dates: Psychological Testing: Provider/Dates: Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other
Youth Pre-Evaluation Screening Date: Time In: Time Out: Interview Location: Individuals Present: Interpretative Aids/Assisted Devices: Pending Felony Charges: ☐ Yes ☐ No Case Number: CMHC Region: In the court of County Voluntary CSU Admission Sought : ☐ Yes ☐ No Mobile Crisis Involvement : ☐ Yes ☐ No Information from this interview will be reported on a standardized form and submitted to the chancery court and civil commitment examiners. You have the right to refuse to participate. Other sources of information including a review of your legal medical records and interviews with family member and the affiant requesting commitment will be included in this report. Respondent Demographics Name: DOB: Age: Gender: Race: Social Sec #: Medicaid #: Medicare#: Home Address: Phone Number: Does the respondent have a legal guardian or conservator: ☐ Yes ☐ No Guardian/Conservator Contact Information Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Affiant Demographics Affiant Name: Relation of Respondent: Number: Home Address: Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Respondent Psychosocial Information Current Living: Current Grade in School: Name of School: History of IEP or 504C: ☐ Yes ☐ No Date of most recent IEP or 504C: Juvenile Justice Involvement: ☐ Yes ☐ No Describe Source of Information: ☐Respondent ☐Affiant Review ☐Other Psychiatric History Current Psychotropic Medications: Dosage & Date/Time Last Taken: Is the medication helpful or problematic: Psychiatric Hospitalizations: Outpatient Treatments: Locations/Dates: Psychological Testing: Provider/Dates: Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
revised-2016-Youth-Pre-Evaluation-Screening-form.docx