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Alpine County Behavioral Health Services Demographic Form Client Name: Revised: 11/16/12 Alpine Client INDEX CARD - ALL CAPS Client Sort Name: Last, First Middle Legal Name: *Last Name: *First Name: Middle: Suffix: *DOB: Soc Sec CLIENT IDENTIFYING INFORMATION - use sentence case Effective Date: Admission Status: Admit *(6)Referral Source: Circle One Referral Phone: Self (13) Jail Family (19) Private MH Practice Friends (26) Criminal Justice /non-SACPA Employer (27) Drug Abuse Program Community Referral (28) Alcohol Abuse Program Health Care Provider (29) School / College (34) CALWORKS (39) SACPA/Prop 36/OTP/Probation or Parole (40) Post Release (AB109) (41) CPS / Dependency Court (43) DUI / DWI (99) Unknown / Not Reported *Birth Name (if different from above): Last Name: First Name: Middle: Suffix: *Physical Address: Apt. *City/State/Zip: *(21)County: *Home Phone: Work Phone: Ext. Cell Phone: *Mailing Address: Apt. *City/State/Zip: *Driver’s License: Yes No DL No.: State: *Social Security (If SSN not entered above) (8)Reason SSN Not Provided: (*If SSN blank) *(7)Gender: Circle One Female Male Other *Is DOB: Actual? Estimated? Born in US: Yes No Born in California: (*If born in US, else disabled and set to No) Yes No Place of Birth: *(21)County: *(22)State: (23)Country: *Mother’s First Name *(9)Marital Status: Not used at this time *(10)Ethnicity: Circle One Not Hispanic Mexican / Mexican American Cuban Puerto Rican Other Hispanic / Latino ---PAGE BREAK--- Alpine County Behavioral Health Services Demographic Form Client Name: Revised: 11/16/12 Alpine Client *(11)Race: Circle One Asian – Other Black / African American Cambodian Chinese Eskimo / Alaskan Native Filipino Guamanian Hawaiian Native Asian Indian Japanese Korean Laotian Mien Samoan Native American Vietnamese ) non-White – Other White Pacific Islander – Other Unknown / Not Reported Hmong Multiple *(12)Primary Language: Circle One American Sign Language Other Sign Language Samoan Other Chinese Tagalog Mandarin Armenian Arabic Chinese Dialect Cambodian English French Cantonese Hebrew Italian Japanese Korean Spanish Lao Turkish Mien Vietnamese Thai Filipino Dialect Other non-English Hmong Polish Ilocano ) Farsai Portuguese Russian Unknown / Not Reported *(13)Communication Method: Circle One Communication Device Sign Language Translator – Spanish Translator – Other Verbal *(12)Language Preferred (Individual): Indicate Code (from prim lang above) **(12)Language Preferred (Caretaker): Indicate Code (from prim lang above) *Interpreter Needed?: Yes No *(14)Employment Status: Circle One Comp Job 35+ hours/week Comp Job <20 hours/week Comp Job 20–35 hours/week Homemaker Rehab 35+ hours/week Rehab 20–35 hours/week Rehab < 20 hours/week Not in labor Force Full Time Student Resident / Inmate Volunteer Other Unemployed, seeking work Unknown / Not Reported Unemployed, not seeking work Retired *(15)Living Arrangement: Circle One Foster Home – Child (10) Comm Treatment Facility (19) SNF/ICF/IMD for SRO – hotel, motel, rooming house (11) State Hospital (21) Correctional Facility – Adult Gp Quarters – dorm, brks, mig camp (12) VA Hospital (22) Correctional Facility – Minor Group Home – LV1 1–12 Child (13) SNF/ICF/NH Physical Health (25) Other House or Apartment (14) MH Rehab Center (26) SA Residential/Rehab House or Apt w/ Support (15) PHF/Inpatient (27) Board & Care House or Apt w/ Supervision (16) Sober Living (28) Residential Treatment Center – LV1 13–14 Supported Housing (17) Specialty Transitional (99) Unknown / Not Reported Residential Treatment Center for the (18) Homeless elderly *Number of Children under age 18 the client cares for/responsible for 50% or more of the time?: *Number of Dependents age 18 or older the client cares for/responsible for 50% or more of the time?: *(16)Education (highest grade completed): Special Education: Yes No District of Residence: Not used at this time *(18)Disability: Circle One Declined to State Developmentally Disabled Mental Health Hearing Speech Mobility Vision Other Disability (not AOD) None *Veteran: Yes No Branch: ---PAGE BREAK--- Alpine County Behavioral Health Services Demographic Form Client Name: Revised: 11/16/12 Alpine Client Alias(es)/Maiden Name Last Name: First: Middle: Last Name: First: Middle: Last Name: First: Middle: Last Name: First: Middle: EMERGENCY NOTIFICATION INFORMATION *Name: *(17)Relationship: See page 4 Address: Home Phone: City/State/Zip: Work Phone: Employment Place: LEGAL INFORMATION *(24)Legal Consent: See page 4 *Responsible Person: *(17)Relationship: See page 4 *Address: Phone: *City/State/Zip: Employment Phone: Employment Place: Responsible Party SSN: MEDICAL INFORMATION *Personal Physician: Phone: FAX: Address: City/State/Zip: Pharmacy: Phone: FAX: Hospital Preference: ADVANCE DIRECTIVE INFORMATION Advance Directive Given? Yes No CLIENT CONTACT INFORMATION May we leave message at home? Yes No May we leave message at work? Yes No May we leave message via emergency contact? Yes No May we leave message on your cell? Yes No May we contact you by mail? Yes No NPP Given? Yes No Form Signed Date: If we cannot contact you by mail, then what is an alternative address or method of contact to send you clinical information such as letters and billing information?