MADONNA HEALTHCARE SERVICES, INC



WINNERS CHOICE HEALTHCARE SERVICES, LLCHavre De Grace, Maryland 21078 Phone : 443-502-5880 Fax: 443-502-5934 Email: Winnershcsprp@ REFERRAL FOR SERVICE Please indicate one of the following: ________ On-site/Off-site _________( Off-site Only)CONSUMER’S IDENTIFICATION INFORMATION (Active Medical Assistance required for PRP Referral)Name: ____________________________________________ Sex: M/F Race: _______________D.O.B.____/_____/_____Social Security Number:______________________________ Home/ Cell Phone:_____________________Address( including city & state)________________________________________________________________Insurance: ___________________________ Policy #:_________________________________________Allergies/Health Concerns: ____________________________________________________________________Highest Level of Education attained: ____________________________________________________________Marital status: Married/ Single/ Divorced/ WidowedEmployment: Yes/ NoIs the consumer a veteran? YES/NO If YES, are they a veteran of : IRAQ/AFGHANISTAN/OTHER: _________ REASON FOR REFERRALCurrent symptoms/mental health status:_________________________________________________________________________________________________________________________________________________________________________________________________________________________What is the consumer expected to gain from PRP services? _________________________________________________________________________________________________________________________________________________________________________________________________________Check all that apply:____ Need help with ADL’s ____Needs help with medication compliance____ Needs help with therapy compliance ____ Has poor/severely impaired skills____ Tends to isolate self ____ Needs help with relapse prevention skills____ Needs help with coping skills ____ Needs help maintaining stable housing DIAGNOSISBehavioral Diagnosis (AXIS I) :_______________________________________________________________Primary Medical Diagnosis (AXIS 3): __________________________________________________________Social Elements Impacting Diagnosis (AXIS 4) :__________________________________________________Functional Assessment (AXIS 5) :______________________________________________________________CURRENT MEDICATIONSName: Dosage: SOMATIC/PSYCHIATRIC_____________________ _______________________________________________________________INPATIENT PSYCHIATRIC TREATMENT HISTORYApproximate number of inpatient psychiatric admissions during lifetime:_________________________Please complete the following for the most recent hospitalizations:Hospital :___________________________ Admission Date:__________ Discharge Date: ______ Hospital: ___________________________ Admission Date:__________ Discharge Date:______DRUG/ALCOHOL HISTORY: Alcohol: YES/NO Date of most recent use: __________________________________________________________Other Drugs: YES/NO List substance(s) and Date(s) of most recent use: ________________________________________________________________________________________________________________________________________LEGAL HISTORYAny current legal issues/concerns: YES/NO/UNKNOWN If YES, please explain:___________________________________________________________________________________________________________________________________Previous/Past legal issues: __________________________________________________________________________________________________________________________________________________________________________________Discuss any history of impulsive, explosive, violent or homicidal behaviors: ___________________________________________________________________________________________________________________________________________FAMILY HISTORY OF MENTAL ILLNESS & HISTORY OF TRAUMA:_______________________________________________________________________________________________________________________-___________________________________________________________________________________________ PROVIDER INFORMATIONTreating Psychiatrist: _________________________________Organization:______________________________Address:____________________________________________ Phone Number:____________________________Mental Health Therapist: _____________________________ Organization:______________________________Address: ____________________________________________ Phone Number:____________________________Primary Care Physician: _____________________________ Organization:______________________________Address: _____________________________________________ Phone Number:____________________________Referred by: (please print) ________________________________ Date:__________________________________ ................
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