DEMOGRAPHICS:

Consumer's Name

Date of Birth

Address

Contact

Phone

Social Security Number

MA#

Marital Status

Race

Gender

Grade

Highest Level of Education

Parent / Guardian

Does Parent/Guardian have legal custody of the minor?

Yes

No

If Parent / Guardian doesn't have custody, please provide custodial information:

Custodial Name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

With whom does this consumer reside?

Does the client have an IEP?

Yes

No

If yes, indicate level of Special Education

Primary Care Physician

Address

Primary Care Phone

Primary Care Fax

FINANCIAL

Employment Status

Payment Source

Income Source

REFERRAL INFORMATION

Referral Clinician Signature

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Date of Referral

Reason for Referral (Client Needs and Presenting Problem)

Pertinent Physiological / Psychological Information

Client Strengths

Activities

Substance Abuse:

Yes

No

If yes, type:

Legal Involvement:

Yes

No

If yes, type:

School Absences (# during the most recent month of school):

Previous/Current Suicidal Ideation:

Yes

No

If yes, please explain:

Past Psychiatric Admission(s):

Yes

No

If yes, provide dates:

Previous Outpatient Treatments:

Yes

No

If yes, provide agencies:

Current Outpatient Provider

Phone

Current Diagnosis

Please check off the following rehabilitation and support services that client may need:

Age Appropriate self-care skills, including:

Indepedent Living Skills including:

Please explain how psychiatric rehabilitation providing the above services circled can help client manage their disorder and/to support recovery as it relates to their treatment goals:

Consumer will benefit from PRP services to help...

Case Management Needs:

**Please forward copies of latest physical, immunization records and custody papers if legal guardian is not the biological parent**

Please attach copy of 90801, and clinical treatment plan.

Referral Form for Minors

DEMOGRAPHICS:

FINANCIAL

REFERRAL INFORMATION

Reason for Referral (Client Needs and Presenting Problem)

Current Diagnosis

CONTACT INFO

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