Virginia Preadmission Screening Report at a glance
What it is: Virginia Preadmission Screening Report 01-22-13 of the Community Services Board/Behavioral Health Authority.
Who signs: The Preadmission Screening Evaluator signs; enter the Date and the Board.
A filled-in Virginia Preadmission Screening Report example: a screening starts at 9:00 am
How to fill out Virginia Preadmission Screening Report, box by box
Date, time and Emergency Custody Order
Enter the Date, the Time From and To, the Time under court order and the Time not under court order, and mark am or pm for From and To.
Under Emergency Custody Order, mark Yes or No, mark Magistrate Issued or Law Enforcement Issued (Paperless), and enter the Date and Time Executed.
For Extension, mark Yes or No and enter the Reason (identify facility/medical evaluation/other good cause).
For Evaluation, mark In-person or Two-way electronic video and audio.
Enter the Petitioner and the Phone, and the Translator and language and the Phone.
DISPOSITION
Under DISPOSITION, mark Recommitment, TDO, Voluntary, CSU, Safety Plan, Release, Referral or Other.
Personal Information
Enter the HOSPITAL/FACILITY and the Case/TDO #.
Under Personal Information, enter the First Name, Middle, Last Name, DOB, Age, SSN, (Gender), (Race), (Hispanic Origin), (Height), (Weight), (Hair Color) and (Eye Color).
Electronically signed and Print Name Here
If electronically signed, mark Electronically signed.
Print Name Here (not required if electronically signed).
Sources
[1] Virginia Preadmission Screening Report 01-22-13, Virginia Department of Behavioral Health and Developmental Services (the Official source link on this page).