Demographic Interview
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
If in a Facility, what is the Facility name?
Facility Phone (if applicable)
-
Area Code
Phone Number
If no facility, what setting do you reside?
Current AHCCCS Health Plan
Client Phone Number (personal)
-
Area Code
Phone Number
What tribe [if applicable] are you from?
If no to tribe, what health home are you assigned to?
Who is your case manager with your home health or tribe?
Yes
No
What is your case manager name?
First Name
Last Name
Unknown who case manager is select this option:
unknown
Phone number to case manager
-
Area Code
Phone Number
Are you seeking treatment on your own freewill?
Yes
No
Do you feel safe where you are at?
Yes
No
Are you in agreement with Teri's Health Services screening and recommending you into the above facility requesting your evaluation today?
Yes
No
Do you have any family or friends or supports of whom you would like me to contact on your behalf to help you? If so, who?
Name and credential of person completing form
First Name
Last Name
Signature of who is reviewing
Submit
Should be Empty: