This government document is issued by Department of Behavioral Health and Developmental Disabilities for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://dbhdd.georgia.gov/document/publication/cs-intake-form-6316pdf/download&sa=U&ved=2ahUKEwiHx77TvfeKAxUABfsDHbzLFLk4KBAWegQIAxAB&usg=AOvVaw1hDqptmgyYCk81JtRwIop0&fexp=72821495,72821494