William J. McCord Adolescent Treatment Facility 910 Cook Road P.O. Box 1166 Orangeburg, SC 29116 (803) 534-2328 Fax: (803) 531-8419 Web Address: www.mccordcenter.com E-mail address: mdennis@tccada.state.sc.us Pre-Screening Form Date: _______________ Name of Referred: ____________________________________________ Date of Birth: ________________________ Address: ________________________________ City: _____________________ County: _________ Zip code: __________ SS #: _______________________ Sex: _______ Parent/Legal Guardian: ___________________________________ Relation to client: ________________________________ Home Telephone #: ( ) ______________________ Work #: ( ) ________________________ Name of person making referral: __________________________ Telephone #: ( ) ______________________ E-mail Address: ______________________________________ Referring Agency:____________________________________ DSS Involvement: _______________________________________________________________________ DSS Caseworker: ________________________________ Tel. #: ( )__________________________ DJJ Involvement: _______________________________________________________________________ DJJ Officer: ________________________________ Tel. #: ( )_______________________________ Reason Referred for Inpatient Treatment: ________________________________________________________ Psychiatric Problems: Medications (name & dosage): __________________________________________________________________ History of Violence: Suicide Attempts: _______________________________________________ Prior Counseling/Treatment Facility: ________________________________________________________ Type Tx: Outpatient ______ IOP _________ Inpatient _______ Dates of Counseling/Treatment: ____________________________________________________________ Payment Information Medicaid #: _______________________________________________________ Insurance Company: _____________________________________________________________________ Policy Holder Name: ________________________________ Policy Holder SS #:___________________ Policy Holder Birthdate: _________________ Group #: ________________________________________ Policy Holder’s Employer: ________________________________________________________________ Benefits Tel. #: ________________________________________________ Precertification Tel #: ___________________________________________ Secondary Insurance: _____________________________________________________________________ Total Family Income: _________________________________per week/ every other week/ month/ year. Total number of people living in house: ____________________ School Information Name of School currently attending or last school attended: _____________________________________ Please circle one: still attending expelled suspended dropped out Date last attended: _______________________ To better assist McCord Center staff in determining if this adolescent meets Inpatient Criteria, the following information should be faxed or mailed to Sabrina Johnson or Mike Dennis at the address listed on the front of this document. Most recent Clinical Assessment Most recent Psychiatric/Psychological Evaluation Last R & E Report Copy of Medicaid/Insurance Card/W-2 form or Paycheck Copies of all drug screens Records from physician/agency prescribing medications