Initial Evaluation Template - Magellan Provider

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Initial Evaluation Template Demographic Information (Please complete all questions on this form). Member Name: ________________________________________ _______. Date: ________________. Name: ________________________________________ ______________________________. Address: ________________________________________ ____________________________. Phone (Home): _________________________ Phone (Work): _________________________. Date of Birth: _______________________ Social Security #: ____. Guardianship (for children and adults when applicable): ____.

Initial Evaluation Template ©2017 Magellan Health, Inc. rev. 11/17 Page 2 Presenting Problem (include onset, duration, and intensity): Precipitating Event (why treatment now):_____ Mental Status (circle appropriate items): Appearance: Appropriate …

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