DATE: ______________ D.A.:_____________________________ RIVERSIDE COUNTY MENTAL HEALTH COURT PRELIMINARY ASSESSMENT NAME: _________________________________________ CASE NO_______________________________ D.O.B.: ______________________________ S.S.#: ______________________________________________ BOOKING NO: _______________________HOUSING: ___________________ CDC#: _______________ ADDRESS/PHONE (OUT OF CUSTODY): ____________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ RELEVANT MENTAL HEALTH INFORMATION: Banning M. H. Blaine Street Clinic Blythe M.H. Main Street Clinic Older Adult Clinic Perris M.H. Client #: __________________________________ RPDC ITF S.C.F. J.W.C. SWDC ETS Hemet M. H. Indio M.H. Temecula M.H. Patton S.H. Other County:________________________________ Parole Outpatient:_______________________________ MEDICATION: (Circle all prescribed medications) Cogentin Depakote Desyrel Prozac Remeron Restoril Zoloft Zyprexa Diagnosis:_______________________________________________________________ Dilantin Effexor Risperdal Selexa Elavil Geodon Seroquel Serzone Haldol Klonopin Lexapro Lithium Tegretol Thorazine Topomax Trazodone Abilify Ativan Benadryl Buspar Mellaril Neurontin Paxil Prolixin Trilafon Vistaril Wellebutrin RELEVANT MEDICAL INFORMATION: Heart Condition Epilepsy T.B. High Blood Pressure Hepatitis (Circle any current illness) Diabetic Other:____________________________________ Alzheimer Arthritis Cancer Back Problem Prescribed Medical Medications:1. ____________________ 2. ____________________ 3. ____________________ 4. ____________________ REGIONAL CENTER CONSUMER: Y/N EDUCATION: Graduated: Yes / No VETERAN: Y/N G.E.D.: Yes / No NATIVE AMERICAN: Y/N Special Education: Yes / No School Attended: ___________________________________________________________________________ INCOME: Employed: (Circle benefits received) Pension Social Security SSI AFDC G.R. Medi-Cal Medicare MISP Private Insurance Kaiser Work History: ________________________________________________________________________________________________________________________ Other:____________________________________________________________________________________ FAMILY CONTACTS: Name: ________________________________________________ Relation: __________________________ Address: _________________________________________________________________________________ Phone: ____________________________________ Cell: _________________________________________ Name: ________________________________________________ Relation: __________________________ Address:_________________________________________________________________________________ Phone: ____________________________________ Cell: _________________________________________ MHCPA-10/14/08 American LegalNet, Inc. www.FormsWorkFlow.com