Behavioral Health Level of Care Screening
Contact & location information: Phone: (725) 237-0080 | email: phpintake.coordinator@healthymindslv.com | 7291 W. Charleston Blvd / Las Vegas, NV 89117
Patient name:
First Name
Last Name
Date of birth (mm/dd/yyyy):
Parent/guardian name:
First Name
Last Name
Parent/guardian phone number
-
Area Code
Phone Number
Parent/guardian email):
Insurance name:
Referral source name:
Referral source phone number:
-
Area Code
Phone Number
Referral source email:
Reasons for referral - Youth displays (click all that apply):
Threats of harm to self or others without intent to cause injury or death
Running away or sneaking out
Frequent RPCs, suspensions, or problems at school
Aggressive acts (hitting, punching) without serious harm
Behavioral decline: using substances, change in peer group, significant withdrawal
Other (if other, please explain below)
If "other" please specify:
Parent/guardian reports (click all that apply):
Consideration of placement disruption
Concerns leading to involvement of law enforcement
Other (if other, please explain below)
If "other" please explain:
Provider, CFT, or treating team is considering/facing (click all that apply):
More frequent clinical visits
More restrictive levels of care
Changing treatment providers due to mental/behavioral health decline
Recent discharge from an inpatient psychiatric facility
Other (if other, please explain below)
If "other" please explain:
Provider note: Healthy Minds' staff will contact the patient within two business days of form completion and submission in order to schedule their assessment. Thank you for your referral.
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