Client Info Form

Parents/Caregivers: Please fill out this portion as completely as possible and return to the assessment facilitator at your next appointment. Feel free to attach documents if necessary.

Identifying Information

Name:

Birth date:

Phone Number:

Mobile Number:

Email:

Address:

Sex:
MaleFemale

Height:

Current Weight:

Hair Color:

Eye Color:

Social Security#:

Medi-Cal#:

Medicare#:

CA ID#:

UCI#:

Conserved?
NoYes

Conservator Name:

Rep Payee?
NoYes

Rep-Payee Name:

Information & Contacts

Allergies:

Medical & Psychological Diagnoses (list all):

List of Current Medications (attach file if necessary):

Primary Care Physician
Name:

Phone Number:

Address:

Dentist:
Name:

Phone Number:

Address:

Psychiatrist/Psychologist
Name:

Phone Number:

E-mail:

Address:

Neurologist
Name:

Phone Number:

Address:

Ophthalmologist
Name:

Phone Number:

Address:

Other Medical Provider
Name:

Relationship:

Phone Number:

Address:

Other Medical Provider
Name:

Relationship:

Phone Number:

Address:

Other Medical Provider
Name:

Relationship:

Phone Number:

Address:

Pharmacy
Name:

Phone Number:

Address:

Pharmacy #2
Name:

Phone Number:

Address:

Important Contacts

Landlord/Apartment Manager
Name:

Phone Number:

E-mail:

Address:

Regional Center Case Manager
Name:

Phone Number:

Fax Number:

E-Mail:

Address:

Day Program/Employer
Name:

Phone Number:

Address:

Contact Name:

E-mail:

IHSS Social Worker
Name:

Phone Number:

County:

Additional Contact Name
Name:

Relationship:

Phone Number:

E-mail:

Family Contacts

Primary Family Contact
Name:

Relationship:

Phone Number:

E-mail:

Secondary Family Contact
Name:

Relationship:

Phone Number:

E-mail:

Additional Family Contact
Name:

Relationship:

Phone Number:

E-mail:

Additional Family Contact
Name:

Relationship:

Phone Number:

E-mail:

Additional Information