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Call Now: 910.960.7491
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About Us
Intake Packet
FAQs
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Services
About Us
Intake Packet
FAQs
Contact Us
Services
About Us
Intake Packet
FAQs
Contact Us
Search
Intake Packet
ARCCCS – Individual Information/Emergency Data Sheet
Admission Date
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE #:
CELL #:
ALTERNATE #:
Can a confidential voice mail be left on Individual’s voice mail?
YES
NO
Can mail be sent to the address above ? If No, please list mailing address below:
YES
NO
CITY:
STATE:
ZIPE CODE:
Type of Insurance/Funding
BC/BS Policy #:
Medicaid: #
NC Health Choice #:
None Other {Please Specify}:
Race
Sex:
MALE
FEMALE
Marital Status:
Single
Married
Separated
Divorced
Widowed
IF Married/Divorced/Widowed, please list Maiden Name:
Primary Language:
DATE OF BIRTH:
Is the Individual their own Guardian? YES NO If No, please list Legal Responsible Person Below.
YES
NO
First
Last
Living Arrangement(s): {All applicable}
If living in a home, please list # of people in household:
Education Information (i.e. school, daycare name)
Education Level at Time of Admission:
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE:
FAX:
Employer Name:
Occupation:
ADDRESS:
CITY:
SATE:
ZIP CODE:
PHONE:
FAX:
Employment Status:
Full-Time
Part-Time
Other
Primary Care Physician:
Carolina Access and/or NPI #:
ADDRESS:
CITY:
SATE:
ZIP CODE:
PHONE:
FAX:
Hospital Preference: If YES, please specify Hospital Name:
YES
NO
Hospital Name:
Emergency Contact:
Relationship:
ADDRESS:
CITY:
SATE:
ZIP CODE:
PHONE:
CELL:
Emergency Comments:
Allergy(s):
Any recent illness?
High Blood Pressure
Diabetes
Cancer
Other (List & Explain):
Any past illnesses? If Yes, List and Explain
YES
NO
Explain:
Family History:
High Blood Pressure
Diabetes
Cancer
Mental Illness
Other (List & Explain):
Explain
Individual Signature (if applicable)
Date
Legally Responsible Person Signature (if Individual is not their own legal guardian)
Date
ARCCCS – Staff Signature (Staff responsible for the completion of this form)
Date
Submit
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