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Psychiatric Hospital Inpatient Admission Form 12357-B Riata Trace Parkway Suite 150 Austin Texas 78727-6422 TMHP CCIP Phone 1-800-213-8877 Fax 1-512-514-4211 I. Identifying information Medicaid Date Last name First name Middle initial Date of birth / Age Sex Date of admission Facility name Referral source Provider Commitment Type if applicable Effective Date Admitting MD Current living arrangements DPRS Time Name of contact person County MH Professional With parent s Group/foster home Judge Other list IIA. Primary symptom described in specific observable behavior that requires acute hospital care Include Precipitating events leading to admission IIB. Other relevant clinical information including inability to benefit from less restrictive setting Attach additional pages or documents as necessary IIC. Psychiatric medications Include total daily dose IID. Present and past drug/alcohol usage Name of chemical Current use IIE* Past psychiatric treatment 1. Number of previous inpatient admissions Dates of most recent inpatient stay to 2. Previous ambulatory/outpatient treatment provider or facility frequency If none why III. Admitting diagnosis Axis I IV. Additional diagnosis Axis I and Axis II V. Functional assessment scores DSM IV VI. No* of hospital days requested Projected discharge date required GAF VII. Aftercare Plan Provider or Facility Frequency Signature Attending MD Print name Provider number Provider license number. Identifying information Medicaid Date Last name First name Middle initial Date of birth / Age Sex Date of admission Facility name Referral source Provider Commitment Type if applicable Effective Date Admitting MD Current living arrangements DPRS Time Name of contact person County MH Professional With parent s Group/foster home Judge Other list IIA. Primary symptom described in specific observable behavior that requires acute hospital care Include Precipitating events leading to admission IIB. Primary symptom described in specific observable behavior that requires acute hospital care Include Precipitating events leading to admission IIB. Other relevant clinical information including inability to benefit from less restrictive setting Attach additional pages or documents as necessary IIC. Other relevant clinical information including inability to benefit from less restrictive setting Attach additional pages or documents as necessary IIC. Psychiatric medications Include total daily dose IID. Present and past drug/alcohol usage Name of chemical Current use IIE* Past psychiatric treatment 1. Psychiatric medications Include total daily dose IID. Present and past drug/alcohol usage Name of chemical Current use IIE* Past psychiatric treatment 1. Number of previous inpatient admissions Dates of most recent inpatient stay to 2. Previous ambulatory/outpatient treatment provider or facility frequency If none why III. Number of previous inpatient admissions Dates of most recent inpatient stay to 2. Previous ambulatory/outpatient treatment provider or facility frequency If none why III. Admitting diagnosis Axis I IV. Additional diagnosis Axis I and Axis II V. Functional assessment scores DSM IV VI. .

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