Triad Therapy LLC



Consumer Referral Sheet

|Consumer Name: |Medicaid # if Applicable: |LME Record # if Applicable: |

Date of Referral: ___________________ Medicaid County: __________________________

Date of Birth: _____________________ Sex : ⃞ Male ⃞ Female

Address: _____________________________________________________________________________________

City:_____________________________________________ State: ___________ Zip Code: __________________

Telephone: (Home) ___________________ (Work) ___________________ (Cell) ________________________

Referral Source: ⃞ Self/ Referral ⃞ LME ⃞ Hospital ⃞ DSS ⃞ Schools ⃞ Doctor

⃞ Family/Relative/Friend ⃞ Other: List ________________________________________________________

Referral Source’s Name: ___________________________________ Phone #: ____________________________

Presenting Problems/ Reason for referral:______________________________________

______________________________________________________________________________

_____________________________________________________________________________________________

Check all applicable Presenting Problems/ Reason for referral:

⃞Housing/ Residential ⃞ Financial ⃞ Legal ⃞Transportation ⃞Family Conflicts

⃞Emotional / Mental Health Tx ⃞Social Medical/Health Issues ⃞Safety Issues ⃞Day Program

⃞Other(s)

Diagnosis: DSM-IV TR Code and Description and/ or Clinical Impression

Axis I Primary: ________________________________________________________________________________

Axis II Primary: _______________________________________________________________________________

Axis III Primary: ______________________________________________________________________________

Current /GAF Score: _____________________

Legal Status (Check all that apply):

⃞Competent ⃞ Incompetent ⃞ Minor Denies legal history ⃞ On Probation/Parole

⃞ Juvenile Court ⃞ In Jail ⃞ Legal history/ prior charges (list) ____________________________________

Guardianship/ Legally Responsible Person / Emergency Information

Who is the Legally Responsible Party? ⃞ Self ⃞ Guardian ⃞ Parent ⃞ LRP ⃞ Other ____________

(Check All that Apply)

Name of Guardian/LRP/Emergency Contact: _____________________________________________

Address of Guardian/LRP/Emergency Contact: ____________________________________________

Home#: __________________ (Work)____________________ (Cell) __________________________

What services does person currently have, have if any? ____________________________________

What services are you requesting? _______________________________________________________

_____________________________________________________________________ ____________________________________

(Signature & Title of Person Completing Referral) (Date

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7830 North Point Blvd, Suite 201 Winston Salem, NC 27106

Office: 336.896.0904 Toll Free: 1.866.74.TRIAD Fax: 336.896.1402

Website: email: info@

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