1-844-SPIN-CAN • 10501 Drummond Rd. Phila., PA 19154

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BH Intake

Referral Source (Program, Family, CBH, Other): *
Referred by: (name) *
Phone Number:*
-

IDENTIFIED CLIENT DEMOGRAPHIC INFORMATION

Name:*
Age:*
D.O.B.:*
 / 
 / 
Gender:*
Primary Language:*
Secondary Language:
Interpreter Needed: *
Primary Insurance Plan Name: *
If Other, Plan Name:
Member ID #
Secondary Insurance Plan Name: *
If Other, Secondary Plan Name :
Secondary Member ID # (type N/A if none):*

*If your PRIMARY insurance is an HMO plan you will need to obtain a REFERRAL from your primary care provider for SPIN PRIOR to your first appointment with us. If you do not have the referral from your primary care provider your appointment will be cancelled.

Any Other Insurance:
Insurance Phone #’s:
Current Address: *
Primary Contact #: *
-
Contact # Type:*
Secondary Contact #:
-
Secondary Contact # Type:
E-mail Address:*
Is client in Foster Care? :*
Foster Parent Name:
Foster Parent Phone:
-
Does client have Case Management? :*
Case Manager Name:
Case Manager Phone #:
-
DHS Worker:*
DHS Worker Name:
DHS Worker Phone #:
-
Does the client have an assigned CUA worker?*
Name of CUA Worker:
CUA Organization:
CUA Worker Phone #:
-
Probation/Parole Officer:*
Name of Officer:
Officer Phone #:
-
Social Worker:*
Name of Social Worker:
Social Worker Phone #:
-

BIOLOGICAL FAMILY INFORMATION

If the client’s biological parent(s) and/or court appointment legal guardian(s) is not present at the time of the appointment the appointment will need to be cancelled and rescheduled. All legal custody/guardianship paperwork must be sent prior to the scheduled appointment via fax or mail.

Are you the identified client’s biological parent? *

(Must bring proof of custody if living with person(s) other than biological Parent(s).)  Proof must state that the person providing treatment consent and attending appointments has LEGAL rights of the child.)

Are you the child’s Legal Guardian? *
(legal guardian must be present for all appointments.)
Is there a custody agreement or court order agreement? :*
Legal Guardian Name:*
Relationship to identified client: *
Legal Guardian Address:
Primary Contact Phone #: *
-
Primary # Type
Legal Guardian Name:(2)
Relationship to identified client: (2)
Legal Guardian Address:(2)
Primary Contact Phone #: (2)
-
Primary # Type (2)
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SERVICE HISTORY

Does the client have an Autism Diagnosis?*
Where was the client first diagnosed?:
Has the client received Behavioral Health services at SPIN? *
If Yes, what services?:

Has the client ever received Behavioral Health Services elsewhere?

Outpatient Therapy:
Outpatient Where:
Outpatient When:
BHRS (Wraparound): *
BHRS WHere:
BHRS When:
Family Based:*
Family Based Where:
Family Based When:
STS:*
STS Where:
STS When:
Other Services:*
Other Services Where:
Other Services When:
Has the client ever been hospitalized or placed in a partial program?*
Where:
When:
Duration:
Does the client currently take any type of Psychiatric Medication?:*
Type of Medication:
Psychiatrist Name/Organization:
Did client receive Early Intervention? *
If YES what type of Early Intervention?
If YES what is the provider name?
Is the client active in:
If so, where?

Past Therapy/Services: 

Psychiatrist (Agency and Name):
Is the client currently in a Special Education classroom?:
School:
Other Medical Concerns:
Other agencies/units involved with:
REASON FOR REFERRAL:
Please enter the text you see in the box
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