Get Cenikor Facility Intake Form 2013-2026

The Cenikor Facility Intake Form is an essential document for individuals seeking treatment at Cenikor. This guide will provide you with step-by-step instructions on how to complete the form online, ensuring that you submit all required information accurately and efficiently.

Follow the steps to complete the Cenikor Facility Intake Form online.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Fill in the date and time of the call for a clear record. Include the screener's name and the appointment date and time.
3. Provide the caller's name and their relationship to the client. Specify the facility related to the intake.
4. In the personal section, input the client's name, date of birth, preferred contact numbers, gender, and age. Indicate if a message can be left.
5. Complete the referral section by detailing how the client learned about Cenikor, selecting from the provided options such as family, internet, or previous clients.
6. For substance use information, indicate any priority populations applicable and provide details about drug types abused, including frequency and last usage.
7. In the treatment information section, disclose if the client has previous interactions with Cenikor and summarize treatment results or discharge reasons.
8. Address any legal issues in the legal section, including arrests, probation, and charges pending, ensuring all relevant details are included.
9. Complete the demographic information, specifying living arrangements, mailing address, and emergency contact details.
10. Fill in the medical and psychiatric information, including primary care provider details and any existing health conditions.
11. Document any current medications and their respective details in the medications section.
12. Provide education and employment history, including current school status, previous jobs, and any relevant obligations.
13. In the financial section, indicate the funding source and the person responsible for payment, attaching any necessary agreement for insurance claims.
14. Review the completed form to ensure accuracy. Save changes, download, print, or share the form as needed.

Finish your paperwork efficiently by completing the Cenikor Facility Intake Form online today.