Preadmission Screening Report Form – Fill Out and Use This PDF

The Preadmission Screening Report is a comprehensive document used primarily within the state of Virginia. It serves as a critical tool for assessing individuals who may require admission to community services or psychiatric facilities, ensuring their needs are accurately identified and that they receive appropriate care. This report covers a wide array of areas, including personal information, legal status, medical and psychiatric history, substance use, and more, to provide a full picture of the individual's situation. If you or someone you know is preparing for a preadmission screening, click the button below to ensure the form is completed accurately.

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Preadmission Screening Report Form PDF Details

The Virginia Preadmission Screening Report, updated on January 22, 2013, serves as a comprehensive document instrumental in the behavioral health assessment and subsequent decision-making process regarding the care and management of individuals encountering the mental health system in Virginia. Designed for detailed completion by Community Services Boards or Behavioral Health Authorities, it meticulously collects extensive information, ranging from personal identification, legal status, medical and psychiatric history, current health status, to more nuanced data such as substance use history, mental status examinations, and the presence of any legal constraints. By covering the assessment phase's broad spectrum—starting from the initial emergency custody status to the final disposition options such as recommitment, temporary detention orders (TDO), voluntary admission, or alternative community service referrals—the form plays a pivotal role in streamlining processes that determine the most appropriate care pathway for the individual in crisis. In essence, it segments out significant details about the individual's background, presenting crisis situation, current behavioral health treatments or services being received, and a thorough assessment including substance abuse assessments and mental status exams, thereby setting the stage for informed decisions regarding the requisite level of care and support services. The structuring of the form also denotes an attempt to address both immediate and longer-term needs by ensuring that the assessment captures a holistic view of the individual's condition and circumstances to guide the trajectory of their treatment and rehabilitation.

Question	Answer
Form Name	Preadmission Screening Report Form
Form Length	10 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 30 sec
Other names	ve, VIRGINIA, NGRI, Code19

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				VIRGINIA PREADMISSION SCREENING REPORT			01-22-13 State FINALVersion

Community Services Board/Behavioral Health Authority: _ _______________________________							Consumer ID# _____________________
Date: ________________________				Time: From ____________ am	pm	To____________ am		pm
Time under court order: __________				Time not under court order: ____________
Emergency Custody Order: Yes			No	Magistrate Issued	 Law Enforcement Issued (Paperless)
Date and Time Executed: _______________________
Extension: Yes	No	Reason: ___________________________________________ (identify facility/medical evaluation/other good cause)
Evaluation:  In-person		or  Two-way electronic video and audio
Petitioner ______________________________________________________________________							Phone:____________________________
Translator and language: __________________________________________________________							Phone: ___________________________
DISPOSITION	Recommitment		TDO Voluntary CSU  Safety Plan			Release Referral Other _______________

HOSPITAL/FACILITY ____________________________________________________ Case/TDO #: _______________________________

Personal Information

First Name: _________________________ Middle: ______________ Last Name: ________________________ DOB: __________Age: ____

SSN: _______ - _____ - _______ _ M / F__________ _________ _______________________________________________________

(Gender)

(Race)

(Hispanic Origin)

(Height)

(Weight)

(Hair Color)

(Eye Color)

Address: ___________________________________________________________________________________________________________

(Street)	(City)	(State)	(Zip Code)	(County)
Phone: (___)___________________Home/Cell	Marital Status: __________		Spouse Name: ____________________________________

School Division (If applicable): ___________________ School Attending: ________________________Grade: ___________ Special Ed.: Y or N

(If under age 18)
Mother: ___________________________ Address: ________________________________			Phone: ___________________ Home/Cell
Father: ____________________________ Address: ________________________________			Phone: ___________________ Home/Cell
Legal Custodian	 Unknown	Name: __________________________Phone: ________________Address:______________________
Legal Guardian	 Unknown	Name: __________________________Phone: ________________Address:______________________

Emergency Contact: Name _________________________Relationship to Person: _________________ Phone ______________________

Address: ___________________________________________________________________________________________________________

(Street)(City)(State)(Zip Code)(County)

CSB of Residence: __________________________________________

CSB Code: _____________Contacted: Yes  No ______________________________________________________________________

(Name)(Phone)

Employment Status:  Unknown____________________________ Education Level: (All ages)_____________________________________

Employer: _______________________________________________________Phone: _____________________________________________

Military Status:  Unknown ______________________________________________Start Year: ______________ End Year: ______________

SSI Yes  No  Unknown				SSDI Yes  No  Unknown

Medicaid:	Yes	 No	 Unknown # ____________________________Subscriber Name: _____________________________________
Medicare:	Yes	 No	 Unknown # ____________________________ Part D: Yes No _______________________________Plan
Insurance: Yes		 No	 Unknown	_________________________________________________________________________________
				(Name of Company/ Group/Plan/Number)

Local Use

Name: _________________________

Page 1 of 10

Collateral Sources
 Individual Requesting Evaluation	 Family/Significant Other/Guardian			 Treatment Records
 Treating Physician/Psychiatrist	 CSB Case Manager or Other Staff				 Police/First Responders
 CIT Officer	 WRAP Plan		 Advance Directive		 Safety & Support Plan
Is CSA (Comprehensive Services Act) involved with minor? Yes			 No	 Unknown
Is Department of Social Services involved with individual?		Yes	 No	 Unknown

Comments:_______________________________________________________________________________________________

______________________________________________________________________________________________________

Presenting Crisis Situation

Referral Source: _____________________________________ Consultation Location: _______________________________

Reason for Referral: _____________________________________________________________________________________

______________________________________________________________________________________________________

Assessment:

________________________________________________________________________________________________________

Name: _________________________

Page 2 of 10

Behavioral Health Treatment/Services
Current Outpatient Treatment:  Yes  No  Unknown	 Behavioral Health (MH - SA)  Developmental Services

 Private Provider or  CSB Name: _________________________________ Phone: ____________________________

Case Manager: _________________________________________________ Phone: ____________________________

Psychiatrist: _____________________________________________________ Phone: ____________________________

Prior Inpatient Treatment:  Yes  No  Unknown  Behavioral Health (MH - SA)  Developmental Services

Name/Location of Last Tx facility: ___________________________________ Adm. Date: _______Discharge Date: _______

Number of Hospitalizations: _______

Ever in a State facility?  Yes  No Name: __________________________________ Date: _____________________

Ever in a Crisis Stabilization Unit?  Yes  No

Name: __________________________ Date: _____________________

Other: _________________________________________________________________________________________________

 WRAP Plan MOT  PACT/ICT	 NGRI	 Advance Directive  Safety & Support Plan  Group Home
 Day Treatment  Prevention Services	 In-Home Provider Name: ___________________________ Other: ___________________

Substance Abuse Assessment
 No current use	 No history of use		 Refuses to answer
Current use listed below:

Drug Type	Priority	Age 1st Use	Frequency of Use	Method of Use	Date of Last Use
			and Amount		and Amount

	Primary

	Secondary

	Tertiary

History of substance abuse  (Drugs, alcohol, mood altering substances, marijuana, prescription medications, inhalants)

Comment: ______________________________________________________________________________________________

_______________________________________________________________________________________________________

Have you or anyone else ever felt you had a drug or alcohol problem?  Yes  No

Have you received inpatient or outpatient SA treatment?  Yes	 No Maintenance services?	 Yes	 No
Number of prior episodes of any drug: ___________	Detoxification treatment?	 Yes	 No

Name/Location of last treatment facility: ____________________________________ Date of Discharge: _________________

						Current withdrawal	History of withdrawal
						(Past 24 hours)

	Tremors

	Headaches

	Vomiting (Blood present)		 Yes	 No

	Nausea

	Diarrhea (Blood present)		 Yes	 No

	Sweating

	Paranoia

	DT’s

	Other

BAC: ________________Time: ________ Lab Results: ________________________  Unable to Test
Tobacco use?  Yes		 No			Type: __________________________________________________________
Pregnant Status:  Yes		 No  Unknown				Pregnant and using substances?  Yes  No  Unknown

Name: _________________________

Page 3 of 10

Mental Status Exam

Appearance:

 WNL

unkempt

poor hygiene

 tense

 rigid

Behavior/Motor

Disturbances:

 WNL

agitated

guarded

tremor

manic

impulsive

psychomotor retardation

 tearful

easily startled

distracted

hysterical

 restless

Orientation:

 WNL

 Disoriented to: time

place

person

situation

Speech:

 WNL

 pressured

 slowed

soft

loud

slurred  incoherent

Mood:

 WNL

depressed

angry

hostile

euphoric

anxious

anhedonic

withdrawn

Range of Affect:

 WNL

constricted

blunted

flat

labile

inappropriate

Thought Content:

 WNL

impaired

unfocused unreasonable preoccupation

delusions

thought insertion

grandiose

ideas of reference

paranoid

obsessions

phobias

Thought Process:

 WNL

 illogical abstract

concrete

incoherent  perseverative impaired concentration

 loose associations

 flight of ideas

circumstantial

blocking

tangential

Sensory:

 WNL

 illusions  flashbacks  Hallucinations:

auditory

visual olfactory

 tactile

Memory:

 WNL

 Impaired:

 recent

 remote

 immediate

Appetite:

 WNL

 increased

decreased

Weight:

 stable

 loss

 gain

Sleep:

 WNL

 hypersomnia

onset problem

 maintenance problem

Insight:

 WNL

 blaming

little

 none

Judgement:

 WNL

 impaired

 poor

Estimated Intellectual Functioning: Above average

 Average

Below average

Diagnosed MR

Unable to determine

Able to provide historical information:  Yes

 No

Explain: ____________________________________________________

Reliability of self report  Good  Fair

 Poor

Explain: ____________________________________________________

Significant Clinical Findings (further describe any symptoms checked above)

_______________________________________________________________________________________________________

________________________________________________________________________________________________________

_____________________________________________________________________________________________________

_________________________________________________________________________________________________

_______________________________________________________________________________________________

Name: _________________________

Page 4 of 10

Medical

Primary Care Provider: _______________________________________________________Phone: _______________________

Medical history and current medical symptoms or issues:

________________________________________________________________________________________________________

___________________________________________________________________________________________________

Medication:	Please see attached medication list 	Please see attached medical addendum 
Current prescribed psychotropic and other medications (include dosage, schedule, etc. if known)
Name	Dose	Schedule	Physician

1._____________________________________________________________________________________________________

2._____________________________________________________________________________________________________

3._____________________________________________________________________________________________________

4._____________________________________________________________________________________________________

5._____________________________________________________________________________________________________

6._____________________________________________________________________________________________________

7._____________________________________________________________________________________________________

8._____________________________________________________________________________________________________

Has individual followed recommended medication plan?  Yes  No Explain: ______________________________________

Has individual followed recommended recovery plan?  Yes  No N/A  Explain: _______________________________

Recent medication change?  Yes  No  Unknown Date of change: ____________________________________________

Describe change: _______________ _________________________________________________________________________

Allergies (including food) or adverse side effects to medications:  Yes  No  Unknown

Describe: _______________________________________________________________________________________________

_______________________________________________________________________________________________________

Legal Data
Legal Status: _______________________		 Unknown
Is individual serving a sentence?	 Yes	 No	 Unknown		Details:___________________________________________
Is individual NGRI Conditional Release? (Adults only)				 Yes  No  Unknown Details: _______________________________
Is individual on probation or parole?  Yes  No			 Unknown		Contact Person: _____________________________________
Pending legal charges?  Yes	 No	 Unknown Charges: _________________________________________________
Date of hearing if known:____________________			Court of Jurisdiction _____________________________________________
If a minor: Judge: ________________________			Attorney: __________________________ GAL: _______________________
Has individual come from detention? Yes  No				 Unknown

Juvenile Detention Center: _________________________________________________________________________________

(Facility Name)(Address)(Telephone)(Fax)

Diagnosis DSM IV R (P- Provisional, H-Historical)

Axis I _______________________________Axis I __________________Axis I ______________________________________

Axis II ______________________________Axis II _____________________________________________________________

Axis III_________________________________________________________________________________________________

Axis IV Psychosocial and Environmental (Check all that apply)________________________________________________________

 Support group	 Social /Environmental	 Educational	 Domestic  Occupational  Housing  Economic
 Health Care	 Legal System	 Other _______________________________________________________
Axis V GAF Current: ___________		Highest past year, if known: ____________

Name: _________________________

Page 5 of 10

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Preadmission Screening Report Form – Fill Out and Use This PDF

Preadmission Screening Report Form PDF Details

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