Adult Services Inquiry Form

Clients accepted into the Adult Services Programs must have a primary diagnosis of Mental Retardation and be 18 years of age or older. Clients must not be abusing any substance or engaging in any homicidal, suicidal or illegal activities. If you would like to speak to someone regarding the admission process, please call (434)-384-3131.
     *  denotes required field

 

*First Name:
Middle Initial:
*Last Name:
*DOB:  
Gender: Male, Female  
 Race:
Married? Yes       
 Pregnant? Yes
 
Referral Source: Name:     
  Relation:
  Address:
  Phone:  
     
*Primary Family Contact: *Name:  
  *Relation:
  *Address:
  *Phone:   
     
*Legal Guardian *Name:   
  *Relation:
  *Address:
  *Phone:
  

                     Does the person have a case manager at the CSB? Yes
If Yes, Case Manager

 

 

 Name:  
Address:
    Phone:
*Service Requested:
Payment Source:
*Current Location:
 
Diagnosis:
  Does the person has a diagnosis of mental retardation? Yes
  Please list all mental health diagnosis:

 
  Please list all medical diagnosis:
 

Does the person has any of the following medical needs:

 

Ventilator Dependent? Yes
Dermal Ulcers III and IV that are unhealed? Yes
Intravenous therapy needed? Yes
Airborne infectious disease--communicable? Yes
Psychotropic medication without diagnosis. & treatment plan? Yes
Nasogastric tubes? Yes
Gastric tube? Yes
Require continuous licensed care? Yes

Other Medical issues:

 
   
 
Is the person currently exhibiting or has

in the past year exhibited the following:

 
Arson or fire setting Yes
Violent behaviors Yes
Threat to self or others Yes
Substance Abuse Yes
Self-injurious behaviors Yes
Sex offender adjudicated Yes
Sex offender/acting out Yes
Suicidal Behavior Yes
Medical issues w/ lack of compliance w/ treatment Yes

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