DEMOGRAPHICS:

Consumer's Name

Date of Birth

Address

Contact

Phone

Social Security Number

MA#

Marital Status

Race

Gender

Highest Level of Education

With whom does this consumer reside?

Primary Care Physician

Primary Care Phone

Primary Care Physician's Address

FINANCIAL

Employment Status

Payment Source

Income Source

Medical Assistance Number

REFERRAL INFORMATION

Referral Clinician Signature

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Therapist, credentials

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 Treatment

Yes

No

If yes, provide agencies:

Current Outpatient Provider

Phone

Current Diagnosis

Primary ICD-10 Code:

Primary ICD-10 Code

Psychosocial/Educational Concerns

Secondary ICD-10 Code:

Secondary ICD-10 Code

Psychosocial/Educational Concerns

Case Management Needs

Please explain how psychiatric rehabilitiation 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 sevices to help...

Case Management Needs:

**Please forward copies of latest physical, immunization records.**

Please attach copy of 90801, and latest clinical treatment plan.

Referral Form for Adults

DEMOGRAPHICS:

FINANCIAL

REFERRAL INFORMATION

Reason for Referral (Client Needs and Presenting Problem)

Current Diagnosis

CONTACT INFO

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