Patient Information Referral Information Referring Agency: Name: Position/Title: Phone/Cell: Fax: Continue Intake Form Date: Last Name: First Name M.I. Age D.O.B Gender: Veteran Marital Status Pregnant IV Drug User Social Security # Medicaid # Bayou Health Plan Provider Guardians Name (If under age) Street Address: City State Zip Code Home phone: Ok to leave a message Cell phone Ok to leave a message Work phone Ok to leave a message Name of emergency contact Relationship to you Address Home phone Cell/Work phone Referral Source (how did you hear about counseling services from whom and what organization) Have you ever been in counseling/therapy before If yes did you find it helpful or effective Are you currently receiving mental health services If yes, please list name of practitioner and type ofservices you are receiving: List any previous hospitalizations, incarcerations, foster homes/group homes due to emotional problems and/or behavioral problems Have you ever been diagnosed with a mental illness? If yes, please list illness(es) and date(s) first diagnosed Have you ever or are you currently engaging in self harm? Currently: Past Have you ever or are you contemplating suicide? Currently: Past Have you ever or are you contemplating harming another person? Currently: Past Have you ever attempter suicide: If yes, please list date(s), method(s), and your age at time of attempt: Do you exhibit physical aggression (hitting, pushing, kicking, bullying, breaking items, holes in walls, screaming, ect.)? Do you exhibit verbal aggression and/or intimidation (cursing, screaming, threatening, ect.)? Do you exhibit dangerous behavior (playing with fire, runaway from home/sneaking out, playing with weapons, getting out of a moving car, ect.)? Substance Abuse (alcohol, illegal drugs, abusing prescription drugs) Truancy(missing /skipping school) Anxiety (worries a lot, bites nails, problem sleeping, nightmares, bed wetting, chewing on things) Depression (cries a lot, no interest in doing things, not many friends, sleeping or eating problems) Suicidal/Homicidal (tried to kill self or someone else) Odd/Strange Behavior/Hallucinations/Delusions(sees things that are not there, hearing voices, talking to self) Negative Effect on Social Life (not invited to parties/relative houses due to behavior, limited friends due to behavior) Name Address Phone Number Number of years of education completed: Degree(s) achieved Nameof School: Ever suspended? If yes, how many times? Ever expelled? If yes, how many times? Reason(s) for suspension/expulsion? What kind of grades is your child making in school? Notes: Signature Date: Continue PDF Title Download Important Numbers Police: 911 LES After Hours: Community Resources: 211 Poison Control: 800-222-1222 Livingston Parish Sheriff: 225-686-2241 OCS Livingston Parish: 225-686-7257 Food Stamp Office (Livingston Parish): 225-686-2261 Food Stamp Office (East Baton Rouge): 225-922-3000 Social Security Office: 800-772-1213 Livingston Parish School Board: 225-686-7044 Denham Springs Medicaid Office: 225-665-1899 Medicaid Transportation: 800-259-1944 Quad Area Action: 225-665-4681 Salvation Army: 225-355-4483 Independent Living Program for the Homeless: 225-267-6977 Helpful Links www.magellanoflouisiana.com www.dcfs.louisiana.gov www.dhh.state.la.us www.nimh.nih.gov www.namilouisiana.org www.laffcmh.org www.chadd.org www.apa.org www.dbsalliance.org www.bpkids.org www.psych.org www.nmha.org www.ffcmh.org www.aacap.org
