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 #: __________________________________ ETS Hemet M. H. Indio M.H. Temecula M.H. Patton S.H. RPDC ITF S.C.F. J.W.C. SWDC Other County:________________________________ Parole Outpatient:_______________________________ MEDICATION: (Circle all prescribed medications) Abilify Ativan Benadryl Buspar Mellaril Neurontin Paxil Prolixin Trilafon Vistaril Wellebutrin Cogentin Depakote Desyrel Prozac Remeron Restoril Zoloft Zyprexa RELEVANT MEDICAL INFORMATION: Heart Condition Epilepsy T.B. High Blood Pressure Hepatitis Diagnosis:_______________________________________________________________ Dilantin Effexor Risperdal Selexa Elavil Geodon Seroquel Serzone (Circle any current illness) Back Problem Diabetic Haldol Klonopin Lexapro Lithium Tegretol Thorazine Topomax Trazodone Other:____________________________________ Alzheimer Arthritis Cancer Prescribed Medical Medications:1. ____________________ 2. ____________________ 3. ____________________ 4. ____________________ REGIONAL CENTER CONSUMER: Y/N VETERAN: Y/N NATIVE AMERICAN: Y/N EDUCATION: G.E.D.: Yes / No Special Education: Yes / No Graduated: Yes / No School Attended: ___________________________________________________________________________ INCOME: (Circle benefits received) Employed: 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