(301) 441-2368
(301) 441-2368
Treatment Plan Acknowledgement
Referral
Intake Form
Client Consent
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Grace And Mercy Health Services
(Health & Nursing Services)
Residential Services
Skilled Nursing
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Homemaking Services
Activities of Daily Living (ADLs)
Developmental Disabilities Services (DDS)
Grace & Mercy Community Services
(Behavioral Health Services)
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Outpatient Treatment (OT) – SUD Level 1.0
Intensive Outpatient Program (IOP) – SUD Level 2.1
Psychiatric Rehabilitation Program (PRP) – Adults & Minors
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Home
About
Services
Grace And Mercy Health Services
(Health & Nursing Services)
Residential Services
Skilled Nursing
Personal Care
Companion Care
Homemaking Services
Activities of Daily Living (ADLs)
Developmental Disabilities Services (DDS)
Grace & Mercy Community Services
(Behavioral Health Services)
Outpatient Mental Health Center (OMHC)
Outpatient Treatment (OT) – SUD Level 1.0
Intensive Outpatient Program (IOP) – SUD Level 2.1
Psychiatric Rehabilitation Program (PRP) – Adults & Minors
Health Home Services
Blog
Gallery
Service Areas
Careers
Contact
Schedule Appointment
Email
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GRACE & MERCY COMMUNITY SERVICES INC. (GMCS)
CONSUMER INTAKE FORM
1. Consumer Identification
Full Name:
Date of Birth:
MM slash DD slash YYYY
Age:
Gender:
Male
Female
SSN:
Medicaid ID:
Address:
Phone:
Email:
Preferred Language:
Interpreter Needed:
Yes
No
2. Emergency Contact
Name:
Relationship:
Phone:
3. Guardian / Legal Representative (if applicable)
Name:
Relationship:
Phone:
Type
Parent
Guardian
POA
Other
Other:
4. Referral Information
Referral Source:
Referred By:
Contact:
5. Services Requested
5. Services Requested
OMHC
PRP
OT
IOP
Health Home
Community Housing
Other:
Other
6. Presenting Problem
6. Presenting Problem
7. Mental Health History
Current Diagnosis:
Symptoms:
Depression
Anxiety
Trauma
Psychosis
Other
Other:
Hospitalizations:
Yes
No
If yes:
8. Substance Use History
Current Use:
Yes
No
Substances:
Frequency:
Last Use:
9. Medical History
Primary Care Provider:
Medical Conditions:
Medications:
10. Risk Assessment
Suicidal Ideation:
Yes
No
If yes explain:
Homicidal Ideation:
Yes
No
If yes explain:
History of Self-Harm:
Yes
No
If yes explain:
11. Social / Living Situation
Living Arrangement:
Independent
Family
Shelter
Homeless
Other
Other:
Employment:
Employed
Unemployed
Student
Disabled
Support System:
12. Signatures
Consumer Name:
Signature:
Date
MM slash DD slash YYYY
Guardian Signature:
Date
MM slash DD slash YYYY
Staff Signature:
Date
MM slash DD slash YYYY
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Full Name
Phone
Email
Best time to Call
Morning
Afternoon
Evening
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Quick Inquiry
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