Core Outpatient – Client Information Form

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Core Outpatient – Client Information Form

Date*
Date Format: MM slash DD slash YYYY
Location*
Name*
First Last
Email*
Date of Birth*
Date Format: MM slash DD slash YYYY
Age
Hidden to keep data, but replaced with DOB
SSN (Last 4 Numbers)*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Alternate Phone
Are you employed?*
- Yes
- No
Emergency Contact Name*
Relationship*
Emergency Contact Phone*
Please READ **If you are having thoughts of harming yourself or others, STOP HERE and call 911 or the GA Crisis Line 1-800-715-4225**
Are you currently a client at this Center or any View Point Health Center?*
- Yes
- No
Do you have insurance?*
- Yes
- No
If yes, what is name of insurance?
Current clients: Are you having problems with your medication?*
- Yes
- No
Current clients: Do you need a refill on your medication?*
- Yes
- No
NEW Clients: How did you hear about us?*
- Friend
- Hospital
- GCAL
- Probation/Parole
- Parent Accountability Court
- Website
If referred by GCAL, when was the referral made?
Date Format: MM slash DD slash YYYY
Tell us why you are here today (check all that apply)*
- To begin outpatient mental health treatment
- To begin outpatient substance abuse treatment
- Recently released from jail/prison
- Open DFCS case
- To be assessed for crisis and/or inpatient treatment/hospitalization or detox
- For information only (stop here)
- Other
If Other, please explain:
If Hospital discharge (within last 2 weeks)
Hospital Name
Hospital Admit Date
Date Format: MM slash DD slash YYYY
Hospital Discharge Date
Date Format: MM slash DD slash YYYY
What problem(s) have you experienced in the last 3 days (check all that apply):*
- Select All
- Depression
- Problems in relationships
- Work/School Stress
- Legal Issues/Court-Mandated
- Anger/Aggression
- Family recommended Treatment
- Domestic Violence
- Thoughts of Killing Myself
- Paranoia
- Change in Sleep Patterns
- Anxiety
- Detox/Alcohol and Drug Use
- Thoughts of Killing Others
- Seeing/Hearing Things Others Do NOT Hear/See
- Other
If Other, Please Explain:
Do you own a weapon, have access to, or are you currently carrying a weapon?*
- Yes
- No
Are you seeking to have paperwork completed for work, SSI, FMLA, etc.?*
- Yes
- No
***Please know that View Point Health no longer prescribes any Controlled Substances (ex: Xanax, Valium, Klonopin, Ativan or any ADHD medications for adults**
***SSI Disability Information Requests*** View Point Health will NOT complete SSI Questionnaires or similar forms about your treatment unless you (A) been in services with VPH for a minimum of (90) consecutive days and (B) been examined by a VPH medical doctor at least once during the 90 days
Agree*
However, even if these conditions are met, View Point Health reserves the right NOT to fill out such documentation. Please Initial:
Initial*
Email
This field is for validation purposes and should be left unchanged.

CARF International accreditation demonstrates a program’s quality, transparency, and commitment to the satisfaction of the persons served. CARF International is an independent, not-for-profit accreditor of human service providers in the areas of Aging Services, Behavioral Health, Child and Youth Services, Durable Medical Equipment, Employment and Community Services, Medical Rehabilitation, and Opioid Treatment Programs. (888) 281-6531.

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Core Outpatient – Client Information Form

If Hospital discharge (within last 2 weeks)