Lic 601 Form – Fill Out and Use This PDF

In Box 1, enter the Name of Client or Child, the Social Security Number (Optional), the Date of Birth, the Age and the Sex.

In Box 2, enter the Responsible Person or Placement Agency, with the Address and the Telephone.

In Box 3, enter the Name of Nearest Relative (Optional), with the Relationship, the Address and the Telephone.

In Box 4, enter the Date Admitted to Facility and the Address Prior to Admission.

Enter the Date Left in Box 5 with the Forwarding Address, and the Reasons for Leaving Facility in Box 6.

In Box 7, for the Person(s) Responsible for Financial Affairs, Payment for Care, Legal Guardian, if any, enter the Name, the Address and the Telephone.

In Box 8, for the Other Persons to be Notified in Emergency, enter the Name, the Address and the Telephone of a. Physician, b. Mental Health Provider, if any, c. Dentist, d. Relative(s) and e. Friend(s).

In Box 9, under Emergency Hospitalization Plan, enter the Name of Hospital to be Taken in an Emergency and the Address of Hospital to be Taken in an Emergency.

Enter the Medical Plan Identification Number, the Name of Dental Plan (if any) and the Dental Plan Number (if any).

In Box 10, under Other Required Information, enter the a. Ambulatory Status and the b. Religious Preference, and the Name and Address of Clergyman or Religious Advisor, if any, with the Telephone.

Use Box 11 for Comments.

Sign the Signature of Resident and the Signature of Person Completing Form, and enter the Title and the Date.

Section B, Residential Facilities for Children: additional information is required by regulation for residential facilities for children.

In Box 1 of Section B, enter the Name of Child; in Box 2, the Name and Address of Person to Contact, if Authorized Representative is Not Available, with the relationship and telephone number.

In Box 3, enter the Name and Address of Parent(s)/Parent's Domestic Partner, if known, with the telephone number.

In Box 4, enter the Child's Court Status and attach custody orders and agreements with parent(s), or person(s) having legal custody; this is optional for small family and foster family homes.

In Box 5, enter the Name and Relationship, the Address and the Telephone of the Person(s) with whom Child has been Living (if known).

In Box 6, under Visitation Restrictions (by Court Order or Authorized Representative), enter the Name and the Relationship of the Person(s) Not Authorized to Visit Child.

In Box 7, specify Family Residence Visitation Restrictions, if any.

In Box 8, for All Persons Authorized to Remove Child from Home, enter the Name, the Relationship and the Specify Conditions.

In Box 9, under Telephone Access, mark YES or NO (by court order) for Make and Receive Confidential Calls, and if NO, specify restrictions.

Use Box 10 of Section B for Comments.

Identification and Emergency Information, a form of the California Department of Social Services Community Care Licensing Division. The H & S Code and the regulations of the Department require this information to be maintained on every person admitted to a community care facility, to be readily available to the person in charge, but not accessible to unauthorized persons. All information must be kept current.