Alliance Wellness Center

Alliance Wellness Center · IRTS Program

IRTS Intake Screening Form

Please complete all sections as thoroughly as possible. This information helps our clinical team determine eligibility and plan for admission to our Intensive Residential Treatment Services program.

Prescribed medications are required prior to admission if the client will arrive with medication. Please ensure prescriber's signed orders are attached or note their status below.

1

Referral Information

2

Eligibility Criteria

3

Support System

4

Client Information

5

Functional Assessment

Cognitive Functioning

Orientation (Person, Place, Time)

Level of Concern

6

Risk Assessment

7

Treatment History

8

Prescribed Medication

Required prior to admission if client will arrive with medication.

9

Current Needs & Goals

★

Screening Outcome

AWC staff will complete this section

Meets Criteria for IRTS

Recommended Level of Care

To be completed by AWC clinical staff

Next Steps (Admission, Waitlist, Referral)

To be completed by AWC clinical staff

Submissions are sent directly to the Alliance Wellness Center clinical team at the IRTS location.