Referral Source Contact Information

Referral Date

Referred By

Referral Source’s Email

Phone Number / EXT.

Agency / Program / Hospital

Individual Referred

First Name *

Last Name *

Date of Birth

Preferred Name

Pronouns

Individual's Address

Address

City

ZIP / Postal Code

State

Phone Number

Other Language

Insurance?

Yes

Insurance provider and insurance number

Mental health diagnosis

Challenges with Activities of Daily Living

(Please select all that apply)

Consistent inability to perform practical daily tasks needed to function in the community, such as maintaining personal hygiene, meeting nutritional needs, recognizing and avoiding common dangers or hazards to self or personal property.

Consistent inability to be employed or to carry out tasks around daily living.

Inability to maintain a safe living situation (e.g., repeated evictions or loss of housing).

Inability to meet medical or health needs, such as inconsistency in medication adherence.

Reason for referral

(Please select all that apply)

High use of acute psychiatric hospitalization or crisis services.

Persistent or recurrent severe major symptoms (e.g., affective, psychotic, suicidal)

Coexisting substance-use disorder of significant duration (e.g., greater than 6 months)

High risk or a recent history of being involved in the criminal justice system.

In substandard housing, homeless, or at imminent risk of becoming homeless.

Living in an inpatient bed or in a supervised community residence but clinically assessed to be able to live more independently if intensive services are provided.

Inability to participate in traditional office-based services.

Personality disorders

Yes

If yes, please describe

Substance use or diagnosis

Yes

If yes, please describe

History of risk: including risk to self (suicidal ideation or attempts.), risk to others, grave disability. Include dates, circumstances, etc.

(if applicable)

History of violence: threats, violence, damage or destruction of property, etc. Include dates, circumstances, etc.

(if applicable)

History of hospitalizations

(including admission/discharge dates):

Developmental disability

Yes

If yes, please describe impact on client’s functioning and ability to participate in services.

TBI

Yes

If yes, please describe.

Housing Status

(Independent, group home, homeless, etc.)