Patient Information Reason for Admission: School: Grade: Grades at School: ⃣ ⃣ Concentration Issues: Behavior at School: YES NO Patient Lives with: Conflicts at Home (if so, who): Abuse History: Medical Concerns: Past medical history: Prior Hospitalizations (if so, when): Family Mental Health History (if so, who): AOD use (ETOH, Caffeine, Cigarettes, and illegal drugs): ⃣ ⃣ ⃣ ⃣ Sexually Active: Safe Sex: Last Bowel Movement: YES NO YES NO ⃣ ⃣ Last Menstrual Period: Pregnancy Concerns: FEMALES ONLY: YES NO ⃣ ⃣ Immunizations Up to Date: YES NO Allergies: Intake Concerns (appetite, N/V, Eating D/O): Sleep Concerns (falling/staying asleep): Number of hours: ⃣ ⃣ ⃣ ⃣ Nightmares: Involuntary Urination at Night: YES NO YES NO Current Medical Medications: Prescribing Physician: Next Apt (Date/Time) ⃣ ⃣ Currently taking Psychiatric Medication: YES NO Current Psychiatric Medications: Previously tried medications: How long has the patient been taking psychiatric medication? Prescribing Physician: Next Apt (Date/Time): How often does the patient see his/her psychiatrist? ⃣ ⃣ Does the patient currently see a Counselor/Therapist: YES NO How long has the patient been in counseling? Name/Number: Next Apt (Date/Time): How often does the patient see his/her counselor/therapist? STATEMENT OF FINANCIAL RESPONSIBILITY & ASSIGNMENT OF BENEFITS Date: ____________________________ *** PLEASE NOTE – ALL SECTIONS MUST BE COMPLETED. ***
Patient Information Reason for Admission: School: Grade: Grades at School: Concentration Issues: ⃣ YES ⃣ NO Behavior at School: Patient Lives with: Conflicts at Home (if so, who): Abuse History: Medical Concerns: Past medical history: Prior Hospitalizations (if so, when): Family Mental Health History (if so, who): AOD use (ETOH, Caffeine, Cigarettes, and illegal drugs): Sexually Active: ⃣ YES ⃣ NO Safe Sex: ⃣ YES ⃣ NO Last Bowel Movement: FEMALES ONLY: Last Menstrual Period: Pregnancy Concerns: ⃣ YES ⃣ NO Immunizations Up to Date: ⃣ YES ⃣ NO Allergies: Intake Concerns (appetite, N/V, Eating D/O): Sleep Concerns (falling/staying asleep): Number of hours: Nightmares: ⃣ YES ⃣ NO Involuntary Urination at Night: ⃣ YES ⃣ NO Current Medical Medications: Prescribing Physician: Next Apt (Date/Time) Currently taking Psychiatric Medication: ⃣ YES ⃣ NO Current Psychiatric Medications: Previously tried medications: How long has the patient been taking psychiatric medication? Prescribing Physician: Next Apt (Date/Time): How often does the patient see his/her psychiatrist? Does the patient currently see a Counselor/Therapist: ⃣ YES ⃣ NO How long has the patient been in counseling? Name/Number: Next Apt (Date/Time): How often does the patient see his/her counselor/therapist? STATEMENT OF FINANCIAL RESPONSIBILITY & ASSIGNMENT OF BENEFITS Date: ____________________________ *** PLEASE NOTE – ALL SECTIONS MUST BE COMPLETED. ***
AC-4-Acute-Admission-Packet-Rev-7-16-(1).docx