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EASA ReferralClient’s Name____________________________Client’s DOB_________________________Client’s Phone number__________________________________________________________Client’s address_____________________________________________________________________________________________________________________________________________Referring agency and person______________________________________________________Referring agency phone number___________________________________________________Referring agency’s relationship to client__________________________________________________________________________________________________________________________Reason for referralPlease mark all that applyReports Hallucinations…__Visual (seeing things other people don’t see.)__Auditory (Hearing things other people don’t hear.)__Tactile (feeling things that are not there i.e. bugs on skin: feeling like a hand is on the person)__Gustatory (Tasting things that are not there.)__Olfactory (smelling scents that others do not.)__Reports Delusions, fixed false beliefs that cannot be corrected by logic and are inconsistent with the person’s culture and education. Reports Perceptual changes…___Fear others are trying to hurt them___Heightened sensitivity to sights, sounds, smells or touch___Statements like, “I think I’m going crazy” or “My brain is playing tricks on me”___Visual changes (wavy lines, distorted faces, colors more intense)___Feeling like someone else is putting thoughts in the brain or taking them outPerformance change…New trouble with___Reading or understanding complex sentences___Speaking or understanding what others are saying ___Coordination in sports (passing ball, etc.)___Attendance or gradesBehavior change…___Extreme fear for no apparent reason___Uncharacteristic, bizarre actions, statements or beliefs___Incoherent or bizarre writing___Extreme social withdrawal___Decline in appearance and hygiene___Sleep (sleep reversal, sleeping all the time, not sleeping)___Dramatic changes in eating.Other___________________________________________________________________________________________________________________How long have these symptoms been present? _____________________________Please provide any relevant information about what may be going on in this person’s life at this current time (i.e. socio economic change: illness: family functioning: transitions etc.)____________________________________________________________________________________________________________________________________ ................
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