Signature Specialty Care Homes- MH Intake Form

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Signature Specialty Care Homes- MH Intake Form

Signature Specialty Care Homes may utilize the information provided in rendering a decision on my acceptance into the home. Any act of dishonesty or failure to disclose pertinent information can and will result in discharge from the home

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Email Address *

First & Last Name *

Phone Number
*

Mental Health History:
• Diagnosed mental health conditions
• Current symptoms or concerns
• Previous psychiatric hospitalizations or treatments
*

Treatment History:
• Current mental health treatment providers
• Medications and dosage
• Therapy or counseling history
*

Triggers and Coping Mechanisms:
• Identified triggers for symptoms
• Coping strategies utilized
*

Social Support:
• Family support system
• Involvement in community or peer support groups
*

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