Form LIC601 Identification and Emergency Information - California

Form LIC 601 Instructions

Enter the following details on the LIC 601 Form:

1. Personal details of the client - name, social security number, date of birth, age, sex. State the details of a responsible individual or placement agency. Also, make sure it is possible to identify the nearest relative. Indicate the date of admission. Once the individual is discharged, write down the date of discharge and reasons for leaving the facility.
2. Person(s) responsible for financial affairs and payments. Add the full name, address, and telephone number of the individual to be contacted in various circumstances, for instance, the legal guardian.
3. Other persons to be notified in an emergency. Provide the personal details of the physician, mental health provider, dentist, relatives, and friends who must be contacted.
4. Emergency hospitalization plan. Name the hospital to be taken to in case of an emergency and provide information about medical and dental plans.
5. Other required information. State the ambulatory status and religious preference.
6. Signatures of the resident and the person who completes the form. Write down the actual date.
7. Residential facilities for children require additional information. State the name of the child, identify the person to contact in case of an emergency, and specify their relationship. Indicate the person(s) with whom the child has been living and any person(s) not authorized to visit the child. Provide personal details of the persons authorized to remove the child from home and specify restrictions on telephone access.