Assessment How to Apply For Our Services Include Assessment and with it Please fax it to 410 779 9400 or email referral to info@newagepsychhealth.com Online Assessment Form Please enable JavaScript in your browser to complete this form.Consumer Name *FirstLastCheckboxesMaleFemaleD.O.B (MMDDYYYY)Guardian Name *FirstLastDoes the Parent/Guardian have legal custody (if minor)? Yes/NoYesNoAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome PhoneCell #Email *Medical Assistance/Medicaid #Is the individual eligible for full funding for Developmental Disabilities Administration services?YesNoHave family or peer supports been successful in supporting this youth?YesNoIs the primary reason for the youth's impairment due to an organic process of syndrome, intellectual disability, a neurodevelopmental disorder or neurocognitive disorder YesNoICD-IO Primary Diagnosis CodeDiagnosing Clinician and TitleClinician AgencyCurrent frequency of treatment provided to this individual (At least Ix/week At least Ix/2 weeks At least Ix/month At least Ix/3months At least Ix/6months)How long has youth been engaged in active, documented outpatient treatment? (Less than one month One visit in the last three months Two or more visits in the last three months)Is the youth transitioning from an inpatient, day hospital or residential setting to the community setting? YesNoDoes the youth have a Target Case Management referral or authorization?YesNoHas medication been considered for this youth? Not considered Considered and Ruled Out Initiated and Withdrawn Ongoing (Other Comments):Upload file if any Drag & Drop Files, Choose Files to Upload Submit
