Susan B. Anthony Center, Inc
Please be sure to complete this form and attach a copy of all the information that is required on the enclosed checklist. For all Yes or No questions, please check the appropriate answer and fill in all explanations if applicable.
Date of Application Tentative admission date
Person Served Name DOB SS#
Race Ethnicity Phone#
Current Address
Referred by Title Phone
Referring Agency
Do you have Insurance Policy Name ID#
Applicants language preference
Substance Abuse History
If applying for substance abuse services please fill out the following, if not, please skip this portion of the application.
Drug of choice Frequency of use Date of last use
Have you ever tried to stop using? If yes, how many times?
What is the longest period of time that you have remained substance free?
Please list any previous treatment programs Person Served has participated in and what caused her to use again?
Medical and Mental Health Information
Do you have any medical conditions or concerns Allergies
Hospitalization in past 12 months
Are you able to perform basic living activities without assistance?
Are you pregnant? If yes, when is the baby due?
Do you have any of the following eating disorders?
Excessive over eating (loss of control, obese)
Have you ever been to a therapist, psychologist, or psychiatrist for mental health problems?
If yes, please give details including diagnosis and any medication that she is on
Compliance with medication in the past 3-4 months
Criminal Justice History
Have you ever been arrested? # of arrests
Behavior under the influence? Date(s)
Sales or possession? Date(s)
Theft? Date(s)
Assault of any kind? Date(s)
Has the Person Served ever been incarcerated? For which Charge?
Length of incarceration?
Currently on probation? Officers Name
Any pending charges? Next Scheduled Court date
If Yes, please describe
Have you been violent in your past? If yes please describe
Educational/Vocational Information
What is the highest grade level completed? Do you have a GED?
Do you have any academic or vocational training? Describe
Where were you last employed? Date you were last employed
Children’s Information
Do you have any children?
Has Child Net or Child Protective Services ever been involved with you or your children?
If yes please explain
Child’s Name Age DOB Gender In Custody of Child Advocate or Investigator Name & Number
Do the children have any mental health problems?
If yes please give details including diagnosis and any medication that child is on:
Do the children have any health concerns? If yes please list them
Homeless History
If applying for homeless services please fill out the following, if not please skip this portion of the application.
Definition of homeless status:
a) Homelessness -- a person sleeping in a place not meant for human habitation or in an emergency shelter, a person in transitional or supportive housing for homeless persons referred from community agencies, hospitals, churches and the police department who originally came from the street or an emergency shelter.
b) At risk of Homelessness -- The client’s substance abuse or mental health diagnosis impedes her ability to maintain stable housing or has put her at risk of losing current housing.
How long has Person Served been homeless or at risk of homelessness?
What lead to homelessness or risk of homelessness?
The following Documents MUST be attached to this application, if applicable:
The following information may be required from the referring facility prior to admission. Please confirm before sending application:
PPD or Chest X-rays Medication List (MAR) Urine Pregnancy Test
Health Assessment U/ARPP Complete Metabolic Panel
History & Phsical Hepatitis Panel CBC
S-TSH Profile Clearances (Medical, Psychiatric, Detox)
HIV (if available, or if client is HIV +has blood work within the past 6 months)
I authorize Susan B. Anthony Center, Inc. to obtain my benefits and eligibility information from any payer whatsoever (including, but not limited to, commercial insurance coverage, ERISA-governed benefit plans, governmental health benefits plans, Medicare, Medicaid, and any other source of welfare coverage or insurance.)
Applicant’s Signature Guardian or Representative Payee
Referring Agency’s Signature Referring Agency’s Name (Print)
To be completed by SBA Staff Applicant
Diagnosis: Current Medications: (Name, Dosage, Frequency, Level of compliance)
Axis I
Axis II
Axis III
Axis IV
Axis V Current GAF
*specify R=refuses, M=moderate compliance, H= high compliance
Directions: For each problem listed, circle the number which best correspond with your knowledge and observation of the client.
Problem List Current Problem Past Problem N/A
1. Suicide Attempts
2. Homicide Attempts
3. Self-Abusive/Self -Destructive
4. Assaultive/Physically Combative
5. Verbally Aggressive
6. Verbalizes Suicidal Ideation
7. Verbalizes Homicidal Ideation
8. Refuses Medication
9. Active Hallucinations/Delusions
10. Substance Abuse
Stage of Change
11. Demonstrates Limited Attention Span
12. Reported Hyperactivity/Pacing
13. Does Not Interact With Peers
14. Does not Protect Self When Accosted By Others (Vulnerable)
15. Does Not Interact With Staff
16. Does Not Comply With Treatment Plan
17. Requires Restraint/Seclusion
18. Requires Close Observation/Supervision
19. Requires Precautions (of Any Type)
20. Requires PRN Meds to Control Behavior
21. Requires Special Physical Care/Monitoring
22. Requires Supervision/Instruction/Assistance
23. Special Educational/Vocational Needs
24. Inappropriate Sexual Behavior
Ability to Understand Illness
Commitment to Rehabilitation
Describe All Unusual Behavior (s)
How will residential placement benefit consumer(s)
Reviewed by
Funding source Primary Secondary
Is Person Served eligible for HOPWA funding? Yes No
Additional Criteria for Admission:
SBA Staff signature Date
Receiving Facility:
1) Please email the completed referral and a copy of the Eligibility Verification print out to Concordia Behavioral Health at in Broward or fax to (305) 514-5321 for initial authorization.
2) Date Screening Completed Accepted (Expected Admission Date
Denied Placed on Wait List (Date & # on List )
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