New Direction Institute, Inc.

Disclaimer: New Direction Institute, Inc. is committed to maintaining the confidentiality of information our clients entrust to us. As clinicians, it is our ethical duty. Our policies on confidentialityand the HIPPA safeguards of your information can be reviewed under the Confidentiality Agreement section of our website.

SCREENING & INTAKE FORM


REFERRAL INFORMATION
Type of Intake:
Date Screened:
Referral Source:
Contact Person:
Address:
Contact Phone #:
CLIENT DEMOGRAPHICS
Client's Name:
Date of Birth:
Social Security Number:
Medicaid Number:
Age:
Sex:
Race:
Address:
Phone Number (H):
Phone Number (W):
CLIENT BACKGROUND INFORMATION
Is client court ordered for services? Yes No
If so, Client is court ordered for: Therapy Psychiatric Evaluation Medication Management
Is Client services for: Mental Health Substance Abuse Dual - Diagnosis
Is client receiving services from any Child Wellfare Providers: Yes Yes, through DCF No
Is client receiving services from any ChildNet Services? Yes No
Presenting Problem:
ADDT'L INFORMATION
Legal Parent / Guardian:
Legal Parent / Guardian Contact Phone Number:
In Case of an Emergency Contact:
In Case of an Emergency Contact Phone Number:
Any Previous Treatment? Yes No
If yes, briefly describe past treatments involving the client, ie- prior hospitalizations, dates, etc.
Present Medications:
Any Disabilities? Hearing Impaired Visually Impaired Other
If other, please describe:
Language Requirement:
Type of Service Requested: Psychiatric Eval. Psychosocial Assessment In-Home Therapy Services Medication Mgmt./Follow Up Social Rehab./Day Treatment Individual Therapy Group Therapy Family Counseling Treatment Plan

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