SF/LTC Referral Screening
|SECURE FACILITY/LONG TERM CARE (SF/LTC) Referral for San Diego Clients |
|Level of care requested (Select one. A separate referral form is needed for each level of care): |
|IMD SD County Funded SNF ARF SNF Patch NBU Patch State Hospital |
|Referring Facility: |Admit date: |Contact name: |Phone: |Fax: |
| | | | | |
|Patient's Name: |DOB: |Age: |
| | | |
|Marital: | |Ethnic: |
| | |
| |TB Screen Date: | |
| |TB Results: | |
|Conservator: Public Private Temporary Permanent Date Established: | |
|Name of Conservator/Court Investigator: | |Telephone # | |
|Comments on Court Investigation: | |
|Name of Case Manager: | |Telephone # | |
|Name of Payee: | |Telephone # | |
|If NO Payee, has an application been made for Payee Services? Yes |Date of Application | |
|Comments: | |
| |
|Diagnosis: Use DSM-IV-TR/ICD 10 Diagnosis and Other Clinical or Medical |Risk Factors | weak strong |
|Considerations | | |
|Primary DX: |
|Dangerous Propensities: |
|Infectious Disease: |
|Reason for referral to this level of care: |
| |
| |
|Comments on current treatment: |
| |
| |
| |
| |
|History of prior hospitalization: |
| |
| |
|Living situation for past 12 months: |
| |
|Legal issues. Note any legal issues including probation, warrants, or interaction with legal system. |
| |
| |
|Treating psychiatrist: | |Phone: | |
|Printed name of psychiatrist: |
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