Form Preview Example


05-2014	EEU APPLICATION FOR SERVICES
(SECTION 1)Demographics and Status Request		Today’s Date: ______________________


Consumer Last name (print):__________________________________		First: _________________________________ MI.:______
SS#: _________________________	DOB: __________________		Age: _________
Gender Expression: ___ (M) ___ (F)	Marital Status: _____________________		Ethnicity: __________________________
TASC Client: Yes ___ No___ Unknown ___	Probation Officer: _________________________________________________
MCI #________________ (if known)	Source and Amount of Income: _____________________________________________
Medicaid #: _________________ Medicare # __________________		Other Insurance (specify): ____________________________

Current Residence (type): ______________________________________________________________________________________

Indicate whether the applicant lives in a private residence (supervised or unsupervised), Adult Foster Care, Boarding House, Group Setting (supervised or supervised), psychiatric inpatient facility (provide name), Nursing Home (specify), other Institutional Setting (specify), homeless or other (explain)

Current Street Address: _______________________________________________________________________________________

City: _____________________________________________ State: __________________________ Zip Code: ____________

Home Phone: ______________________ Work Phone: _________________________Cell Phone: _________________________

Person to Contact in Case of an Emergency: ________________________________________________________________________

Address: ____________________________________________________________________________________________________


Telephone Number: ________________________________			Relationship: ______________________________________________
Primary Language: ( ) English	( ) Spanish	( ) American Sign Language		( ) Other: __________________________
Does the enrollee have a guardian? _____(no)		_____________________________________________________(yes/specify)
Does the enrollee have a representative payee? _____ (no)			______________________________________________ (yes/specify)

LOC Requested: (e.g., ICM or ACT or SUD residential, etc.) _________________________________________________________

Current LOC and Provider: _____________________________________________________________________________________

Application completed by: (print) ___________________________________ (signature) ________________________________________________

Referring Agency: _______________________________Phone/ext.: _______________________ FAX #:______________________

FOR MH SERVICES ATTACH A RECENT (WITHIN LAST 6 MONTHS) PSYCHIATRIC EVALUATION* WHICH INCLUDES THE INDIVIDUALS DIAGNOSTIC PROFILE

*Psychiatric evaluation must be signed by the individual completing the evaluation

Psychiatrist or Psychiatric Prescriber who performed the evaluation and formulated the diagnosis:

__________________________________________________________________________________

(Print Name)

Phone #: __________________________ Date of Diagnosis: _______________________________

(except “no known risk,” explain any item checked)

05-2014

EEU APPLICATION FOR SERVICES

(SECTION 2)

A. What is the most important thing the client wants or made the client decide to call or come in for help right now? “What is most important to you that you would like help with right now?” Document what the client wants, not what you as the clinician believes the client should be working on.)

________________________________________________________________________________________

B. ASAM Dimensions: Provide a brief narrative for each dimension that explains your Rating of Severity/Function. Focus on brief relevant history information and relevant here and now information. CHECK ALL ITEMS THAT APPLY

Dimension 1: Acute Intoxication and/or Withdrawal Potential - Substance Use: Include Amount, Duration and Last Use for each substance

No known risk

Adequate ability to tolerate/cope with intoxication or withdrawal symptoms

Some difficulty tolerating/coping with intoxication or withdrawal discomfort

Past history of complicated withdrawal needing medical intervention

Current potential for complicated withdrawal needing medical intervention

Use is current and complicated withdrawal needing medical intervention is imminent

____________________________________________________________________________________________________________

Dimension 2: Biomedical conditions/complications (except “no known,” explain any item checked)

No known biomedical conditions/complications

 Current physical illnesses exist, and are:

stable

unstable

acute (circle as appropriate)

There is a history of chronic conditions

____________________________________________________________________________________________________________

_________________________________________________________________________________________________

Dimension 3: Emotional/Behavioral/Cognitive Conditions or Complications:

SUICIDALITY (except “no history,” explain any item checked)

No history or current suicidal ideation

Has frequent passive thoughts of being better off dead

Exhibits suicidal ideation without a plan

Exhibits suicidal ideation with a plan

Has recently attempted suicide or made credible threats with a plan and means

Has a history of suicidal gestures or threats

_________________________________________________________________________________________________

SELF-CONTROL/IMPULSIVITY (except “no history,” explain any item checked)

05-2014

EEU APPLICATION FOR SERVICES

Has no history of self-control/impulsivity issues

Is involved with the judicial or legal system

Has been arrested for alcohol- or drug-related crimes, or for use/possession/distribution of drugs, for minor theft, destruction of property, vagrancy/loitering, disturbing the peace, or public intoxication within the past 6 months

Currently experiencing problems related to gambling

Has a history of arrests for illegal or unsafe activities

_________________________________________________________________________________________________

DANGEROUSNESS (except “no known history,” explain any item checked)

Has no known history of dangerousness

Lacks impulse control/control of violent behavior

Has a history of violent or dangerous social behavior

Exhibits inappropriate or dangerous social behavior dangerous to others, e.g. physical or sexual assault, fire setting

Engages in behavior dangerous to himself/herself

Engages in behavior dangerous to property

Engages in behavior that leads to victimization

_________________________________________________________________________________________________

SELF-CARE (except “no self-care deficits,” explain any item checked)

No self-care deficits noted

Does not seek appropriate treatment/supportive services without assistance or requires significant oversight to do so; needs services to prevent relapse

Requires assistance in basic life and survival skills (i.e. locating food, finding shelter)

Requires assistance in basic hygiene, grooming and care of personal environment

Engages in impulsive, illegal or reckless behavior

Experiences frequent crisis contacts (____ (number) within ___ (number) months)

Experiences frequent detoxification admissions (____ (number) within ____ (number) months

_________________________________________________________________________________________________

PSYCHIATRIC/EMOTIONAL HEALTH (except “does not exhibit signs/symptoms,” explain any item checked)

Does not exhibit signs/symptoms of psychiatric or emotional illness

Psychiatric symptoms are well managed with medication/treatment

Symptoms persist in spite of medication adherence

Psychiatric symptoms and signs are present and debilitating

Experiences delusions and/or hallucinations which interfere with client’s ability to function

Acute or severe psychiatric symptoms are present which seriously impair client’s ability to function

Currently taking medications for these symptoms (list below)

Medication adherence is inconsistent

Experiences mood abnormality (depression, mania)

Is frequently very anxious or tense

Is unable to appropriately express emotions

Experiences hopelessness, apathy, lack of interest in life

Experiences physical symptoms related to their psychiatric illness or addiction (e.g. sleeplessness, stomach aches)

Lacks any sense of emotional well-being

PSYCHIATRIC/EMOTIONAL HEALTH/continued

05-2014EEU APPLICATION FOR SERVICES

_________________________________________________________________________________________________

Current medications and dosages. You may attach a copy of your Medication Administration Record (MAR) or order sheet if it is legible.

Medication	Dosage	Effectiveness
1. _______________________________	___________________	_____________________
2. _______________________________	___________________	_____________________
3. _______________________________	___________________	_____________________
4. _______________________________	___________________	______________________
5. _______________________________	___________________	______________________

Allergies: ______________________________________________________________________________________

Dimension 4: Readiness to Change:

UNDERSTANDING OF ILLNESS AND RECOVERY (explain any item checked)

Exhibits understanding of the nature of his/her mental health and/or substance use illness and/or physical health and its effects

Exhibits some understanding of the nature of his/her mental health and/or substance use illness and/or physical health and its effects

Little or no understanding of the nature of his/her mental health and/or substance use illness and/or physical health and its effects

Limited understanding of the nature of his/her mental health and/or substance use illness and/or physical health and its effects

Does not have an understanding of his/her illness(es) and recovery

_________________________________________________________________________________________________

DESIRE TO CHANGE (explain any item checked)

States desire to change

Indicates some desire to change

Limited desire or commitment to change

Doesn’t understand the need to change

Relates to treatment with some difficulty and establishes few, if any trusting relationships

Does not use available resources independently or only in cases of extreme need

Does not have a commitment to recovery

_________________________________________________________________________________________________

05-2014

EEU APPLICATION FOR SERVICES

Dimension 5: Relapse, Continued Use, Continued Problem Potential:

CURRENT AND PREVIOUS TREATMENT HISTORY AND RESPONSE (explain any item checked)

Takes medication with good response/complete remission of symptoms

Takes medications (with or without assistance) as prescribed with continued symptoms/partial remission of symptoms

Not using but no behavioral changes to support recovery

Not taking prescribed medications with a history of violence

Previous or current treatment has not achieved remission of symptoms

Previous treatment exposures have been marked by minimal effort or motivation and no significant success or recovery period was achieved

Attempts to maintain treatment gains have had limited success

Has had extensive and intensive treatment

Has had some treatment

This is the first treatment

 Court ordered to treatment ____ (civil) ____ (criminal)

_________________________________________________________________________________________________

Treatment Service history. Include all inpatient and outpatient treatment. We are particularly interested in the past 24 months or since last placement summary. If more space is needed, attach additional page(s).

DATES		PROVIDER	Effectiveness (treatment goals met,
			premature discharge before goals
			met; problems encountered)
FROM	TO

RELAPSE PREVENTION, ILLNESS MANAGEMENT AND COPING (explain any item checked)

Has awareness of relapse triggers and ways to cope with MH breakthrough symptoms and/or substance use cravings

Has some awareness of relapse triggers and ways to cope with MH breakthrough symptoms and/or substance use cravings

Is unaware of relapse triggers and ways to cope with mental health breakthrough symptoms and/or substance use cravings

Lacks skills to control impulses to use or harm self or others

Doesn’t follow medication regimen

Requires assistance and/or support to actively manage relapse prevention

Tolerates organized daily activities or environmental changes

Exhibits some tolerance for organized daily activities or environmental changes

Has little tolerance for organized daily activities or environmental changes

Is unable to tolerate organized daily activities or environmental changes (e.g. activities or changes cause agitation, exacerbation of symptoms or withdrawal

Is unable to cope with stressful circumstances associated with work, school, family or social interaction

Lack of resilience in response to stress

_________________________________________________________________________________________________

Dimension 6: Recovery Environment:

05-2014

EEU APPLICATION FOR SERVICES

RECOVERY ENVIRONMENT: (except “safe affordable housing of own choosing,” explain any item checked)

Resides in safe affordable housing of own choosing

Resides in safe affordable housing but is not of own choosing

Resides in licensed Adult Foster Care

Resides in unlicensed Adult Foster Care

Resides in a Group Home

Resides in Supervised Housing/Apartment

Living arrangement puts client at risk of harm

Living environment increases client’s stress

Unable to or only marginally able to support themselves in independent housing

At risk of eviction due to behavioral health problems

At risk of homelessness for other reasons (e.g. family refuses to allow a return to the home, community complaints…)

Homeless

There is serious disruption of family or social milieu due to illness, death, severe conflict, etc.

Estranged from their family

Significant difficulties in interacting with family members

Lacks ability to provide food for self or dependent children

No transportation

No child care presenting a barrier to participate in treatment

Language barriers interfere with full participation in treatment

Resides in environment where easily victimized

Other

___________________________________________________________________________________________________________

INTERPERSONAL/SOCIAL FUNCTIONING (explain any item checked)

Has several close relationships or group affiliations

Has one or two close relationships or group affiliations

Lacks connections to supportive social systems in the community

Unable to form close friendships or group affiliations

Unable to interact appropriately with family and/or the community

Unable to engage in meaningful activities

Is socially isolated

Is in abusive relationship(s)

_________________________________________________________________________________________________

Client Strengths that will help him/her be successful at this level of care:

__________________________________________________________________________________________________________

Possible Barriers to treatment:

__________________________________________________________________________________________________________

Question	Answer
Form Name	Eeu Application For Services Form
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	DANGEROUSNESS, eeu application, TASC, ICM

Eeu Application For Services Form – Fill Out and Use This PDF

Eeu Application For Services Form PDF Details

Form Preview Example

Eeu Application For Services Form isn’t the one you’re looking for?

Eeu Application For Services Form – Fill Out and Use This PDF

Eeu Application For Services Form PDF Details

Form Preview Example

Eeu Application For Services Form isn’t the one you’re looking for?

Related Documents