This customizable document, Initial Intake Form, is taken from MCN Healthcare’s Behavioral Health Partial Hospitalization Program Policy and Procedure Manual. For more than 20 years, MCN has been the health care industry’s leading provider of policy and procedure templates, forms, competencies and other compliance tools.

MCN provides more than 80 health care specific policy and procedure manuals for Acute Care Hospitals, Ambulatory Care, Behavioral Health, Home Health, Physician Practice, and Long Term Care. MCN’s policy and procedure manuals focus on the latest healthcare "hot topic" issues related to patient safety and prevention of medical healthcare errors.

Here is some sample content from Initial Intake Form:

	INITIAL INTAKE FORM Referral Source: Patient Name: Address: DOB: Ethnicity: Medicare #: SS#: Secondary Insurance: Conservator/Guardian: Address: B&C Facility: Address: Facility Protocols: Administrator: Medical Doctor: Psychiatrist: Notify in Case of Emergency: Name: Address: Medications: Special Diet: Precipitating Factors Warranting Admission: Behavioral Problems: Reference #2004 Partial...
Second excerpt:
	... Medications: Special Diet: Precipitating Factors Warranting Admission: Behavioral Problems: Reference #2004 Partial...