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northeast iowa mental health & disabilities services ... - Fayette County

northeast iowa mental health & disabilities services ... - Fayette County

APPENDIX F: PREFERRED

APPENDIX F: PREFERRED INPATIENT MEDICAL FACILITIES Covenant Medical Center (including Sartori) Waterloo, Iowa Allen Hospital Waterloo, Iowa St. Luke’s Hospital Cedar Rapids, Iowa Mercy Medical Center Cedar Rapids, Iowa Mercy Medical Center North Iowa Mason City, Iowa University of Iowa Hospitals and Clinics Iowa City, Iowa Mental Health Institute Independence, Iowa 37

Form A: CPC APPLICATION FORM NORTHEAST IOWA COUNTIES CPC/COMMUNITY SERVICES COUNTY CPC Application Form Application Date: Date Received by CPC Office: ____________________________ Last Name: First Name: __________________________ MI: __________ Maiden Name: Nickname: Suffix: __________ Phone #:_________________ Birth Date:_____________ SSN#______________________ State ID#___________________ Current Address: Mailing Address: Street City State Zip County Street City State Zip County Gender: Male Female Ethnic Background: White African American Native American Asian Hispanic Other _______ U.S. Citizen: Yes No Primary Language: Marital Status: Never married Married Divorced Separated Widowed Legal Status: Voluntary Involuntary-Civil Involuntary-Criminal Probation Parole Jail/Prison Veteran Status: Yes No Branch & Type of Discharge: ____________________Dates of Service: ______________ Guardian/Conservator appointed by the Court? Yes No Protective Payee Appointed by Social Security? Yes No Legal Guardian Conservator Protective Payee Legal Guardian Protective Payee Conservator (Please check those that apply & write in name, address etc.) (Please check that apply & write in name, address etc.) Name: _______________________________________ Name: _______________________________________ Address: ______________________________________ Address: _____________________________________ Phone: _______________________________________ Phone: ______________________________________ Living Arrangement: Alone With relatives With unrelated persons Current Residential Arrangement: (Check applicable arrangement) Private Residence State Resource Center Supported Comm. Living State MHI Foster Care/Family Life Home RCF/MR RCF/PMI RCF ICF ICF/PMI Correctional Facility Homeless/Shelter/Street ICF/ MR Other________________________________ Disability Group/Primary Diagnosis: Mental Illness Chronic Mental Illness Mental Retardation Developmental Disability Substance Abuse Brain Injury Specific Diagnosis determined by:_________________________________________________________ Date:__________ Axis I: _____________________________________________________Dx Code: ____________________________ Axis II:_____________________________________________________ Dx Code: ____________________________ If agency referral, name of agency/contact person and contact information: _____________________________________ Referral Source: Education: Self Community Corrections Years of Education: _________________ Family/Friend Social Service Agency GED: Yes No Targeted Case Management Other Other Case Management H.S. Diploma: Yes No College Degree: ____________________ 38

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