SLIDE 7 BEHAVIORAL HEALTH SERVICES ACCESS AND REFERRAL
CALL CENTER REGISTRATION QUESTIONS
- 1. Registration Date: Date Field
Client ID: Numerical Field
- 2. Registration Site: Drop Down Choices
Screener: Drop Down Choices
- 3. Calling for yourself/someone else?: Drop Down Choices
Relationship to client: Drop Down Choices
- 4. Referral Source (Choose one only): Drop Down Choices
Client was referred by: Drop Down Choices
- A. CLIENT DEMOGRAPHIC INFORMATION
- 5. First Name:
Last Name: Middle Initial:
- 6. Date of Birth (MM/DD/YYYY):
SSN: Gender (M/F): If F, Pregnant: (Y/N)
- 7. Enrolled in School (Y/N/NA):
School Name: Drop Down Choices School District: Drop Down Choices Is Child receiving special education services? (Y/N)
MediCal #: Free Text Field
- 9. Covered CA Health Plan (CCHP) (Y/N): CCHP #: Free Text Field
- 10. Private Insurance or Health Plan (Y/N): Private Insurance or Health Plan Name: Drop Down Choices
Private Insurance or Health Plan #: Free Text Field
VHP #: Free Text Field
- 12. PCP/Clinic: Drop Down Choices with Free Text Field
- 13. TAY Client: Y/N TAY Criteria: Drop Down Choices
Conservator information: Free Text Field
- 14. Race: Drop Down Choices Ethnicity: Drop Down Choices
Origin: Drop Down Choices Language/Preferred Language: Drop Down Choices (Above should default to previously entered data for returning clients)
- 15. Number of Children Under 18 Year Old Living with Client: Numerical Field
- 16. How many are 5 years or younger: Numerical Field
- 17. Homeless: Y/N
In a Group Home/Facility (SLE/THU/Res Tx): Y/N Other: Free Text Field
- 18. In the past 60 days (if jail then before) were you homeless, living in a place you don’t own/rent: Y/N
- 19. In the past 2 years, how many months have you not had a place to live?: Drop Down Choices
(If greater than 6 months and in CJS, select Homeless Grant Source) Address: Street: Apt #: City: Zip: Phone: Phone 2:
- 20. Do you require any accommodations we need to inform the provider: Free Text Field
- 21. Have you served in the military (Y/N):
- 22. Criminal Justice Status: Drop Down Choices
Criminal Justice Consent on file (Y/N):
- 23. If on Parole, list name of parole agent: Free Text Field
- 24. If on Probation or Pretrial, list name of probation officer: Free Text Field
- 25. Do you have a Dependency Case? (Y/N)
(If yes, refer to Dependency Assessor)
- 26. Consumer Declined Services (Y/N)
- 27. Date Declined: Date Field
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BEHAVIORAL HEALTH SERVICES ACCESS AND REFERRAL
CALL CENTER REGISTRATION QUESTIONS
- 28. Once done with Registration, transferred to Clinician (Y/N)
If N, referred to Others: Drop Down Choices
- A. ADDITIONAL CLIENT DEMOGRAPHIC INFORMATION FOR CHILDREN AND YOUTH (0-18 YEARS OLD)
CLIENTS
- 29. Caregiver Name: Free Text Field
Caregiver Phone #: Caregiver Address: Caregiver Ethnicity: Caregiver Language:
- 30. Involved with Child Welfare? (Y/N/NA)
If Y, DFCS Social Worker Name: Free Text Field DFCS Social Worker Phone #:
- 31. Child Living Arrangement: Free Text Field
- 32. School Information:
(Captured in Section A – Client Demographic Information )
(Captured in Section A – Client Demographic Information )
