Transcription of Initial Evaluation Template - Magellan Provider
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Initial Evaluation Template - Magellan Provider
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): ____. Marital Status (check one): Race (optional): [] Never Married [] Divorced [] White [] Native American [] Married [] Separated [] African-American [] Asian [] Widowed [] Cohabiting [] Hispanic [] Other Gender: [] Male [] Female Age: _____.
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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