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Richmond, VA, 23224

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New Test Form

Client Screening Form 645.B.1

Note: The following questionnaire is designed to assist staff in identifying specific issues that may affect placement of and/or services to be provided to prospective individuals of our organization. Please review the questions on this list, and answer as completely as possible. This form is intended to provide information needed in evaluating suitability for placement and developing a plan of care if the applicant is admitted

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- Step 1 of 12

Date of Initial Contact

Date of Assessment

Relationship to applicant of person referring applicant *

Legal authorized representative
Individual
Other

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Name of Individual (Last, First): *

Gender *

Date of Birth

SSN

Medicaid

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Address *

Address Line 1

City

State

Zip Code

Phone

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Select the service you are interested in: *

Sources of Information (family, friends, therapist, medical records, school staff, etc.):

Family Member
Therapist; (name and agency)
School records or staff (name and school)
Medical records (specify physician and date of record)
Psychosocial/CBHA/Assessment: (specify type of document and agency)
Others

Name and Agency

Specify Physician and Date of Record

Name and School

Specify Type of Document and Agency

Other Details

Reason why the individual is requesting services: *

Current place of residence: *

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List of services client currently receiving and describe effectiveness:

Individual/Family/Group Therapy (specify type and name of therapist)
Mentor (name and phone#)
Certified Behavioral Analyst (contact info)
Psychiatric Services (specify name, agency, phone#)

Specify Type and Name of Therapist

Certifield Behavioral Analyst Contact Info

Mentor Name and Phone

Psychiatric - Specify Name, Agency and Phone

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effectiveness: emergency? client

Mental/Developmental Status

⦁ Does the client have any of the following diagnosis:

Mental Disorder *

Yes
No

Developmental Disability *

Yes
No

Physical Disabilities *

Yes
No

Your answer is yes, please describe.

The Condition:

Does the client use prescription medications? If yes please list:

The severity of the disorder or disability:

Does the client use any non-prescription medications? If yes please list:

Any current or previous treatment:

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Does the client have any of the following?

Asthma *

Yes
No

Epilepsy *

Yes
No

Allergies *

Yes
No

Diabetes *

Yes
No

Eating Disorders *

Yes
No

Visual Impairment *

Yes
No

Physical impairment *

Yes
No

Infection Disease *

Yes
No

Special Diet *

Yes
No

Pregnancy *

Yes
No

Chronic Medical Condition *

Yes
No

Incontinence *

Yes
No

Type and severity of the condition:

The treatment the client is receiving for the condition:

Name and dosages of the medication the client receives:

Does the client need assistance with eating, dressing, bathing, grooming or toileting? *

Yes
No

Does the client have any special treatment or specific therapies needed as a result of any medical conditions? *

Yes
No

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BEHAVIORS

Does the client have a history of any of the following?

Physical assaultiveness *

Yes
No

Cruelty to others *

Yes
No

Violence to self or others *

Yes
No

Verbal assaultiveness *

Yes
No

Attempt to poison others *

Yes
No

Stealing *

Yes
No

Sexual assaultiveness *

Yes
No

Use of weapons *

Yes
No

If the answer to any of the above question is yes, please describe:

The behaviors:

The frequency and duration of the behaviors:

The approximate date of the last occurrence of behaviors:

Is there anything that seems to trigger the behavior:

Strategies to deal with the behavior:

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Does the individual have a history of any of the following?.

Depression or withdrawal *

Yes
No

Suicide attempts *

Yes
No

Restlessness or hyperactivity *

Yes
No

Anxiety *

Yes
No

Paranoia *

Yes
No

Inappropriate sexual activity *

Yes
No

Mood Swings *

Yes
No

Hallucination *

Yes
No

Non-compliance *

Yes
No

Suicide ideation *

Yes
No

If the answer to any of the above question is yes, please describe:

The approximate date of the last occurrence of behaviors:

The behaviors:

Is there anything that seems to trigger the behavior:

The frequency and duration of the behaviors:

Strategies to deal with the behavior:

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Does the individual have a history with any of the following?

Disruptiveness *

Yes
No

Ingestion of toxic substances *

Yes
No

Refusal of Medications *

Yes
No

Tantrums *

Yes
No

Substance Abuse *

Yes
No

Refusal of Medical treatment *

Yes
No

Wandering *

Yes
No

Resistance to authority figures *

Yes
No

Refusal to bathe or wear clean clothes *

Yes
No

AWOL *

Yes
No

If the answer to any of the above question is yes, please describe:

The approximate date of the last occurrence of behaviors:

The behaviors:

Is there anything that seems to trigger the behavior:

The frequency and duration of the behaviors:

Strategies to deal with the behavior:

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Does the individual have any mental/physical disabilities that would interfere with his/her ability to evacuate the facility in the event of an emergency? If so please explain:

Does the individual have any specific personal needs for assistance with instrumental activities of daily living? (Ex: help getting out of bed, help walking, eating, brushing teeth etc.) If yes please explain:

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Disposition

Applicant accepted into program *

Yes
No
Decision Pending

If no, was client referred to other services, put on waiting list, or referred for further assessment?

Please attach a referral form into this screening form if the client was not admitted to the program and referrals for other programs and/or other services were made.

Applicant or Authorized Representative Signature

Clear Signature

Date

Upload Supporting Documents (Max 10)

Click or drag files to this area to upload. You can upload up to 10 files.

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Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

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Email *

A Different World Services is dedicated to empowering individuals with intellectual and developmental disabilities through personalized care, community involvement, and skill-building programs.

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