CTCHCS Smart Intake — Auto-Fill Packet

👤 Staff Member

Face Sheet

All information entered here will auto-populate across the entire 32-page packet.

Client Identity

First Name *

M.I.

Last Name *

Date of Birth *

Age (auto)

MA #

Gender

Race / Ethnicity

Courts adjudicated legal status?

Yes No

Address & Phone

Street Address

City

State

ZIP

Home Phone

Cell Phone

Work Phone

Employed At

Employer Phone

Legal Guardian / Parent

Guardian First Name

Guardian Last Name

Relationship to Client

Biological Parent?

Yes No

Same address as client?

Yes No

Guardian Home

Guardian Cell

Guardian Email

Emergency Contacts

Contact 1 — Name

Relationship

Home Phone

Cell Phone

Contact 2 — Name

Relationship

Home Phone

Cell Phone

Section 1 of 10

School Information

Pages 2 of the original packet. Complete for minor clients.

School Details

Name of School

Grade Level

Street Address

City

State

ZIP

School Phone

School Fax

Presenting Problems at School

Does client have an IEP?

Yes No

Consent Initials

I consent for CTCHCS staff to meet with my child in the school setting and communicate with teachers, administrators, and school staff regarding progress. (School-Based Services)

I consent for CTCHCS staff to sign my child in or out of school to facilitate mental health treatment delivery. (Early Dismissal)

Section 2 of 10

Medical Information

Page 3 of the original packet.

Section 3 of 10

Insurance Information

⚡ Auto-filled from Face Sheet

Insurance Details

Last Name

First Name

Address

Social Security #

DOB

Race

Insurance MCO

Medicaid / Medicare #

Membership #

Group #

Other insurance?

Yes No

Other Insurance Type / Name

Other Membership #

Section 4 of 10

Coordination of Care

⚡ Patient name and DOB auto-filled

Dr. Orlando Davis — Care Coordination Form (Page 5)

Patient Name

Patient DOB

Date of Communication

Documentation of Counseling / Psychotherapy prior to Medication Management

Documentation / Communication of other issues to other physicians / providers

Communication FROM Dr. Davis

Communication TO Dr. Davis

Section 5 of 10

Entitlement Assessment

⚡ Client and guardian names auto-filled

Client & Consent (Pages 6–7)

Client Name

Guardian Name

Consents to rehabilitation services?

Both Psychiatric & Therapy Only Psychiatric Only Therapy No

Significant medical problems?

Yes No

Requires somatic care follow-up?

Yes No

Follow-up frequency (if yes)

Section 6 of 10

Crisis Management & Safety Plan

⚡ Client name auto-filled

Crisis Assessment Screen (Page 9)

Client Name

Date of Screen

Presenting Symptoms / Behaviors at Assessment

Suicide Risk

Danger to Self or Others

Urgent / Critical Medical Condition

Immediate Threats

Personal Safety Plan (Page 10)

Client Name

Date of Admission

Rationale for Creating Plan

Potential Problematic Symptoms

What triggers the concerning behavior?

Personal Safety Interventions

Public Safety Interventions

Warning Signs of Relapse / Antecedent Behavior

Client's Reported Natural Supports

Any Advanced Directives?

Yes No

Section 7 of 10

Rights, Consents & Policies

Pages 11–20. Initials confirm each policy has been reviewed.

Consent to Treatment (Page 14) — Initials Required

Treatment: I understand my right to appropriate evaluation, diagnosis, and to be informed about treatment options. I may withdraw consent in writing at any time.

Participation: I am willing to enter into and actively participate in outpatient services and agree to participate in developing my Individual Treatment Plan.

Transportation: I authorize CTCHCS to transport me or my child and significant family members as necessary when feasible and safe.

Services: I understand all information about CTCHCS services. Consent remains in effect until revoked in writing or until discharge.

Risk Management (Page 15) — Initials Required

I verify as a client of CTCHCS that I will not bring concealed weapons, drugs (illicit or licit), alcohol, or other contraband onto any CTCHCS facilities or events.

Controlled Substances (Pages 16–19) — If Applicable

Diagnosis requiring controlled substance treatment

Opioid Use Disorder Chronic Pain Syndrome Chronic Anxiety Disorder Other

Prescribing Doctor

Pharmacy on File

Pharmacy Phone

Policies & Procedures (Page 20) — Initials Required

Medication: Only a licensed physician may prescribe medications. No CTCHCS staff will prescribe, including over-the-counter medications.

Notice of Eligibility / Discharge: I understand the conditions under which I may be discharged from services, including missed appointments and inappropriate behavior.

Fee Determination: I understand CTCHCS's fee structure and sliding scale policy. Fees are collected monthly. Special circumstances can be discussed with the Program Director.

Section 8 of 10

PHI Authorization & HIPAA

⚡ Client name and DOB auto-filled

Authorization to Use and Disclose PHI (Pages 24–25)

Client Name

Client DOB

Authorize CTCHCS to (check all that apply)

Disclose information Request information Exchange information

With Name of Person or Entity

Entity Address

Entity Phone / Fax

Purpose for Disclosure

Assist in Treatment Planning Continuity of Care Other

Other Purpose (if applicable)

HIPAA (Page 22) — Initials Required

HIPAA: I agree to allow CTCHCS to use and share my Protected Health Information (PHI) as needed for treatment, payment, and healthcare operations.

Confidentiality (Page 21) — Privacy Practices

I understand the confidentiality and privacy practices policy

Yes, understood

Minor Medical Consent (Page 23) — If Applicable

Minor's Name

Minor's DOB

Authorized Caregiver Name

Relationship

Authorization Valid From

Authorization Valid To

Preferred Hospital or Treatment Center

Section 9 of 10

Pharmacy, Orientation & Financial

⚡ Client name auto-filled throughout

Pharmacy Information (Page 28)

Client Name

Date

Primary Pharmacy Name

Pharmacy Address

Pharmacy Phone

Pharmacy Fax

Previously used this pharmacy?

Yes No

Medication allergies?

Yes No

Allergy Details

Affirmation (Page 30)

Client Name

Services requested

OMHC Therapy OMHC Psychiatric

Relationship of Representative

Clinic Rules (Page 31)

Client Name

Financial Agreement (Page 32)

Member Name

Monthly Income

Sources of Income

Does member have MA?

Yes No

Will member be billed?

Yes No

MA #

Type

Exp. Date

Other Insurance Company

Policy Number

Charge Per Day (if billed)

✍ Signatures — Section 10

Parent / Guardian Signature

Draw your signature above

✓ Confirmed

Staff Signature —

Draw your signature above

✓ Confirmed

🗎 Carelon Behavioral Health Attestation — Section 11

Carelon Behavioral Health - Maryland, Attestation to Discharge Conflicting/Overlapping Authorization(s). The participant (or authorized representative) attests and agrees to the attestation. This is filed with the intake and completed by staff on the Command Center. Your Section 10 signature above is used as the participant signature.

I am the participant (or the participant's authorized representative / legal guardian) and I attest and agree to the Carelon Behavioral Health attestation, requesting services with this provider and the discharge of any conflicting/overlapping authorization(s). This decision is voluntary and made without coercion.

If authorized representative, brief description of authority (optional)

Section 10–11 of 11

👪 Another child in this household?

Download this child's PDF first. Then click below to start the next child with the shared household info already filled in.

Changing Turn Community HealthCare Services

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More than one child in this household?

Face Sheet

School Information

Medical Information

Insurance Information

Coordination of Care

Entitlement Assessment

Crisis Management & Safety Plan

Rights, Consents & Policies

PHI Authorization & HIPAA

Pharmacy, Orientation & Financial