Form19 - q Client demographic and clinical information...

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[ FORM 19 —Use the top of this page for your letterhead.] First-Contact Record Date: Time: A.M./P.M. Case record #: Identification Name of caller: Name of client: Caller is q client q spouse/partner of client q parent q legal guardian q legal custodian q other: Usable phone number (day/eve/work/call): Client’s address: Referral source (“How did you get my name?”): Chief complaint (in client’s exact words): Urgency estimate: q Emergency; immediate interventions q Serious disruption of functioning; act in next 24 hours q Treatment needed; act soon/routine q Wait for: Triage q Referral to: for: q First appointment scheduled for: at A.M./P.M. at (location): Given: q Goals for first meeting? q Directions? Map? q Cancellation costs and method? Any questions? Financial information Credit card: Name on card: Card #: Exp. date: Social Security #: Driver’s license #: Things to do before first appointment Call: at: about: q Send preappointment letter, client information brochure, and these forms:
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Unformatted text preview: q Client demographic and clinical information forms q Adult/child concerns checklist q Developmental history q Financial information form q Agreement to pay q NPP q Other: Performance monitoring Return call: Date: Time: A.M./P.M. Initials of call returner: Call response latency: Days: Hours: Appointment response latency: Days: Hours: This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. FORM 19. First-contact record. Boldface items are important to complete during first contact. From The Paper Office . Copyright 2008 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copy-right page for details)....
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