Consent-Form-EnglishDownload Consent-Form-TamilDownload Consent-Form-GujaratiDownload Consent-Form-MarathiDownload GCC Research Screening Form Email Name of the Interviewer First Last Date of Screening MM slash DD slash YYYY Name of the Facility and LocationPlace of Stay in Facility Open Ward Closed Ward Cell Other Upload Client Consent FormMax. file size: 2 GB.Client Name Aliases Age (in years)Gender Male Female Other Religion Hindu Christian Muslim Buddhist Jain Sikh Other Primary Languages Known Gujarati Hindi Marathi English Other Select AllOther Languages Known Add RemoveType of Admission Voluntary (self-referral) Voluntary (brought by family) Compulsorily Detained (Magistrate) Compulsorily Detained (Other) Voluntarily Brought by Police Other Compulsorily Detained (Other)?Rescued By/Admitted By Rescued At Date of last Admission MM slash DD slash YYYY Number of times previously admitted to and discharged from the same facilityMention Dates if availableNumber of times previously admitted to or discharged fromMention Dates if availableWrite placement details for each dischargeFamily/facility, relationship with client, reason for readmissionPsychiatric Diagnosis Schizophrenia Acute psychosis Bipolar disorder (history of mania) Bipolar disorder (no history of mania) Paranoid state Senile or presenile Dementia Other organic psychosis Depression Obsessive compulsive disorder Chronic mixed anxiety Chronic mixed anxiety Personality disorder Mental Retardation (MR) MR with Psychosis No current psychiatric illness Other Other Psychiatric Diagnosis Add RemoveConcurrent Disabilities Blindness Low-vision Leprosy cured person Hearing impairment Locomotor disability Dwarfism Autism Spectrum Disorder (ASD) Intellectual disbility Cerebral palsy Muscular Dystrophy Chronic neurological conditions Specific learning disabilities Multiple sclerosis Speech and language disability Thalassemia Hemophilia Sickle Cell disease Acid attack victim Parkinson's disease Other Other Concurrent Disabilities Add RemoveList of Comorbid Physical Health Conditions Add RemoveList of all Medications Add RemoveSignificant physical illness/serious injury/self harm/suicide attempts during stay at facilityMention the event with dates, reasons, interventions offered, etc.When did client first experience homelessness?, how many years ago?Details of family and other support networksAddress and contact of client/familyNotes of occupational therapist (if any)Details of criminal history (if any)Any other important details to add (if any) Δ
