Dashboard
Admission Checklist
Authorization and Consent
Authorization for Use of Image
Authorization for Use or Release of Information
Belongings List
Consent for Ordinary and Routine Medical and Dental Care
Consent For Services
Consent for Treatment
Geriatric Depression Scale
Inpatient Certificate
Intake Questionnaire
Legal Notice to Patients
Notice Regarding Rights of Recipients
Observation Record
Patient Phone and Visitation Restriction Sheet
Petition For Involuntary/Judicial Admission
Psychiatric Medical Clearance Checklist
Psychotropic Medication Notice and Consent
Rights Receiving Mental Health Services
Suicide Safety Plan
Unit Rules
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Intake Questionnaire
Referring Agency
Patient Name
Patient DOB
Patient Age
Location of Patient
Living Situation
With Spouse
With One Parent
With Friend
With Family
With Both Parents
Unknown
Shelter
Nursing Home
Independently
Homeless
Halfway House
Group Home
CILA Home
At Multiple Locations
Assisted Living facility
DCFS Ward
Yes
No
Address
Insurance Type
Discharge: Eligible to return to prior living arrangement?
Yes
No
Lock-Out Risk Factors
Presenting Concerns
Spectrum/developmental challenges/learning disability
Yes
No
Past Psych Hx
Past Psych Hospitalization
PMH
Contact
Title
MD
APN
Time
Contact
Title
Time
Admit Time
Refusal Time
Authorized By
Staff Concerns
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