subject_line

Please answer all questions, then click 'Submit' below to complete:

Demographics

Program referring to *

Lumberton Facility Based Crisis Center (Adults 18 +)

SECU Youth Crisis Center (Ages 6-17)

Name *

Date of Birth * +

Street Address

Address Line 2

City *

State *

Zip Code

County of Residence *

Ethnicity

Social Security Number

Insurance Name *

Policy Number *

Sex Assigned at birth

Male

Female

Gender Identity & Sexual Orientation

Preferred Pronouns

Allergies

Guardian Name *

Guardian - Contact Number *

Guardian - Relationship *

Referring Organization/Facility Name *

Referral - Contact Number *

Referral - Email Information *

Referral Type (check box) *

DSS

DJJ/Court/Legal

MCO

Family

Provider Agency

Hospital

Other

Specify County

Specify MCO

Hospital

Provider Agency (specify)

Other

Status

Voluntary

IVC

Clinical/Medical Information

Explain the current crisis the individual is experiencing *

Has individual exibited the following (check all that apply and elaborate in Comments box)

Suicidal Ideation

Comments (include history and most recent occurrence)

Homicidal Ideation

Comments (include history and most recent occurrence)

Self-Injurious Behavior

Comments (include history and most recent occurrence)

Elopement

Comments (include history and most recent occurrence)

Aggression towards people

Comments (include history and most recent occurrence)

Aggression towards property

Comments (include history and most recent occurrence)

Sexualized Behavior

Comments (include history and most recent occurrence)

Eating Disorder

Comments (include history and most recent occurrence)

Substance Use - frequency, last used, and withdrawal symptoms:

Alcohol

Comments (frequency, last used, and withdrawal symptoms)

Stimulants (cocaine, amphetamines)

Comments (frequency, last used, and withdrawal symptoms)

Cannabis

Comments (frequency, last used, and withdrawal symptoms)

Opioids

Comments (frequency, last used, and withdrawal symptoms)

Nicotine/vaping

Comments (frequency, last used, and withdrawal symptoms)

Sedative/Hypnotic (Benzodiazepines, barbiturate, GHB)

Comments (frequency, last used, and withdrawal symptoms)

Hallucinogens (LSD, PCP, psilocybin, MDMA)

Comments (frequency, last used, and withdrawal symptoms)

Current Diagnosis

Current Medications

Current services (type/program) & provider information (name & phone number) where individual is receiving

Discharged from hospital/ inpatient within last 7 days?

Yes

No

Reason for hospitalization or inpatient setting

The individual is able to perform ADLs

Independently

With verbal prompting

Total assistance needed

Please explain assistance needed

Date of last physical exam +

Issues noted from exam

Medical concerns or history

Diabetes

Comments

Hypertension

Comments

Seizures

Comments

Asthma

Comments

TBI

Comments

CPAP needed/used

Comments

Fall History

Comments

Currently Pregnant

Comments

Other relevant medical issues known:

Comments

None Known

Is individual currently involved with legal?

Yes

No

Explain why individual is involved with legal

Please attach as applicable

Clinical Assessments

Provider notes

Hospital records/ Discharge summary

Labs

Any other pertinent information

Attach files here

How did you hear about Monarch’s services (Please select all that apply) *

Family member or friend

Online Search (Google, Bing, etc.)

Social Media (Facebook, Instagram, etc.)

Advertisement (Radio, TV, billboard, etc.)

Referral from a health care provider or community agency

Other (specify ________) Other (specify ________)