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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