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Referral Form for: FORMCHECKBOX Adult PHP FORMCHECKBOX Adolescent PHP FORMCHECKBOX Eve Adult DDIOP FORMCHECKBOX Day Adult DDIOP FORMCHECKBOX OutpatientDate/ Time: FORMTEXT ?????Referral Source/Phone #: FORMTEXT ?????Patient Name: FORMTEXT ?????Date of Birth: FORMTEXT ?????Patient Home Phone #: FORMTEXT ?????Cell Phone#: FORMTEXT ?????Patient Address: FORMTEXT ????? Leave message: Yes FORMCHECKBOX No FORMCHECKBOX If applicable, complete this section:Parent/Guardian Name(s): FORMTEXT ????? Home Phone #: FORMTEXT ????? Cell Phone #: FORMTEXT ?????Parent/Guardian Address: FORMTEXT ?????Insurance Information If applicable, complete this section:Subscriber Name: FORMTEXT ????? Insurance: FORMTEXT ????? ID#: FORMTEXT ????? Subscriber Name: FORMTEXT ????? Insurance: FORMTEXT ????? ID#: FORMTEXT ????? Family member involvement? FORMCHECKBOX Yes, specify below FORMCHECKBOX No If yes, Name/Relationship: FORMTEXT ????? Phone #: FORMTEXT ?????Transportation: FORMCHECKBOX Yes, specify FORMTEXT ????? FORMCHECKBOX NoReason for Referral: FORMTEXT ?????Current thoughts of killing self? FORMCHECKBOX Yes, specify FORMTEXT ????? FORMCHECKBOX NoCurrent thoughts of harming or killing anyone else? FORMCHECKBOX Yes, specify FORMTEXT ????? FORMCHECKBOX NoIf yes to either question, please call 911 or 211 if in immediate dangerCurrent Medications: FORMTEXT ?????Psychiatric Treatment HistoryAny current or past involvement with psychiatric treatment? FORMCHECKBOX Yes, specify below FORMCHECKBOX No ServiceAgency/Identified Individual FORMCHECKBOX Inpatient FORMTEXT ????? FORMCHECKBOX Residential FORMTEXT ????? FORMCHECKBOX PHP/IOP FORMTEXT ????? FORMCHECKBOX Outpatient FORMTEXT ????? FORMCHECKBOX Medication Management FORMTEXT ????? FORMCHECKBOX Case Management FORMTEXT ????? FORMCHECKBOX Other FORMTEXT ?????Substance Use HistoryCurrent Use FORMCHECKBOX Yes FORMCHECKBOX No Type of substance, frequency, and amount: FORMTEXT ?????Past Use FORMCHECKBOX Yes FORMCHECKBOX NoType of substance, frequency, and amount: FORMTEXT ?????Current or Past Substance Use Treatment History: FORMTEXT ?????Medical History FORMCHECKBOX Yes, specify FORMTEXT ????? FORMCHECKBOX No Primary Care Physician/Pediatrician: FORMTEXT ?????Allergies: FORMTEXT ?????Fall HistoryDoes the patient use a device – cane or walker? Yes FORMCHECKBOX No FORMCHECKBOX Does the patient require or need assistance to walk or get around? Yes FORMCHECKBOX No FORMCHECKBOX Does the patient require or need assistance to rise from a chair? Yes FORMCHECKBOX No FORMCHECKBOX Does the patient have a history of a fall within the last 90 days? Yes FORMCHECKBOX No FORMCHECKBOX Legal History Current issues FORMCHECKBOX Yes, specify FORMTEXT ????? FORMCHECKBOX No Are you currently on a sex offender registry? FORMCHECKBOX Yes FORMCHECKBOX No Are you currently assigned a probation officer? FORMCHECKBOX Yes, specify FORMTEXT ????? FORMCHECKBOX No Past Issues FORMCHECKBOX Yes, specify FORMTEXT ????? FORMCHECKBOX NoOther AgenciesAny current or past involvement with other agencies? FORMCHECKBOX Yes, specify below FORMCHECKBOX No AgencyIdentified Individual FORMCHECKBOX Dept. of Children & Families FORMTEXT ????? FORMCHECKBOX Elderly Protective Services FORMTEXT ????? FORMCHECKBOX Other FORMTEXT ?????If applicable, complete this section:Employment FORMCHECKBOX Yes, specify FORMTEXT ????? FORMCHECKBOX No If applicable, complete this section:EducationName of School FORMTEXT ????? Grade FORMTEXT ????? Contact Person FORMTEXT ????? Special Education? FORMCHECKBOX Yes FORMCHECKBOX NoDSM 5/ICD 10 Psychiatric DiagnosesDiagnosis Code: FORMTEXT ?????????? Description: FORMTEXT ?????Diagnosis Code: FORMTEXT ????????? Description: FORMTEXT ?????Diagnosis Code: FORMTEXT ????? Description: FORMTEXT ?????Diagnosis Code: FORMTEXT ????? Description: FORMTEXT ?????Primary Medical Diagnoses: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Z codes: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Social Elements Impacting Diagnoses: FORMCHECKBOX None FORMCHECKBOX Educational Problems FORMCHECKBOX Financial Problems FORMCHECKBOX Housing Problems (Not Homelessness) FORMCHECKBOX Occupational Problems FORMCHECKBOX Problems with Access to Health Care Services FORMCHECKBOX Homelessness FORMCHECKBOX Problems Related to Legal System/Crime FORMCHECKBOX Problems with Primary Support FORMCHECKBOX Problems Related to Social Environment FORMCHECKBOX Other Psychosocial/environmental Problems: FORMTEXT ????? Functional Assessment: GAF FORMTEXT ?????SignaturesProvider Name/Credentials: FORMTEXT ?????If applicable, complete this section:Supervisor’s Name/Credentials: FORMTEXT ?????Provider Signature: FORMTEXT ?????Date: FORMTEXT ?????Supervisor’s Signature: FORMTEXT ?????Date: FORMTEXT ?????Upon completion, fax copy to Alyssa Meehan, Triage Clinician at (860) 496-6783. Thank you. ................
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