Nevada Division of Child and Family Services Mental Health Admission Call Intake Client Name [LAST, First MI] Avatar MR#: Statement of Problem and Comments: Screening Date: / / Disposition: Intake date: Intake time: Intake with: Client Financial/Insurance Coverage [an additional Financial/Benefit form may also be completed] Medicaid Number: Medicaid Fee for Service Medicaid Managed Care: Private Insurance: No Insurance Total # in Household: Client Admission Admission Type: Admitting Practitioner: Admission Date: / / Program: Source of Admission: Primary Presenting Problems Client Demographics
Nevada Division of Child and Family Services Mental Health Admission Call Intake Client Name [LAST, First MI] Avatar MR#: Screening Date: / / Statement of Problem and Comments: Disposition: Intake date: Intake time: Intake with: Client Financial/Insurance Coverage [an additional Financial/Benefit form may also be completed] Medicaid Number: Medicaid Fee for Service Medicaid Managed Care: Private Insurance: No Insurance Total # in Household: Client Admission Admission Date: / / Admission Type: Admitting Practitioner: Program: Source of Admission: Primary Presenting Problems Client Demographics
Attachment_A_Mental_Health_Admission_Form_8_5_16.docx