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Has the patient had any past suicide attempts?:
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If yes, when was his most recent attempt? What method was used?:
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In the last 12 months, has the patient had any thoughts of suicide, along with an intention and plan?:
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If yes, when was his last suicidal thought, along with an intention and plan?:
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Currently, does the patient have any thoughts of suicide along with an intention and plan?:
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Has the patient ever been hospitalized for a mental health condition?:
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Please list all medication and food allergies:
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Has the patient ever had a seizure?:
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Please list all current medications, dosage, and the reason they are prescribed:
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Is the patient currently taking antipsychotic or other psychiatric medication?:
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Does the patient currently have a 30 day supply of his antipsychotic or other psychiatric medication or does he have valid refills?:
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If the patient does not have a 30 day supply of his antipsychotic or other psychiatric medication he may be required to see a psychiatrist or his physician who can prescribe the patient his medication. The patient's cost for this service is $100-$300 depending on his psychiatric service need.
Is the patient taking the medications as prescribed?:
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Please list any immediate medical concerns:
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In the past six months, has the patient had any rashes, wounds, abscesses, respiratory diseases, or other infections?:
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If yes, please describe the situation and the treatment that the patient received:
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Has the patient attended any drug and alcohol treatment centers in the past?:
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If yes, when was the date of his previous treatment?:
Date Format: MM slash DD slash YYYY
Does the patient drink alcohol?:
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Has the patient abused prescription medications or used street drugs in the past 12 months?:
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If yes, please list all substances used as well as how frequently the patient uses them:
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Date the patient last used drugs or drank alcohol?:
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In the past 12 months, has the patient been arrested?:
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The River Source reserves the right to disqualify applicants for specific medical reasons that require a higher level of care. These medical reasons include but are not limited to:
-active Tuberculosis
-suicidal ideation with a plan, means, and/or intent
-acute psychosis
-infectious disease
A person who moves to a higher level of care will again become eligible for River Source program once medical situation is successfully handled.
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