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Date Received:

Staff Initials:

Bonita House, Inc. – Dual Diagnosis Residential Treatment Program

REFERRAL FORM

*Fax completed form and clinical assessments to 510-526-2887

|POTENTIAL CLIENT INFORMATION |

|DATE of REFERRAL: ________________________ |

|Name of potential client:       Current Living Situation: ________________      |

|Address:       City:       Zip:       |

|Phone:       DOB:       Age:    SSN:       Gender:    |

|REFERRAL SOURCE INFORMATION |

|Name and Title of Referring Person:      ___________________________________________________________________________ |

|Referral Type: Self Clinician Psychiatrist Case Manager/Service Team Behavioral Health Care Agency |

|Referring Agency:       ____________________ Phone:       |

|Potential Client’s Psychiatrist:       _____________________ Phone:       |

|Conservator/Legal Guardian, if applicable:      _____________________ Phone:       |

|PAYMENT INFORMATION Alameda County Medi-Cal Private Pay |

|Medi-Cal ID#:       Date Issued:       PSP#:       |

|Does this potential client have a monthly income? Yes No |

|If yes, what is the source of income? SSI SSDI Other Amount per month, if applicable: $      |

|Payee Name, if applicable:       Phone:       |

|ICD-10 DIAGNOSES / DSM IV CODES are required for referral review; MUST HAVE both a Psychiatric Disorder AND Substance Use Disorder): |

|Diagnoses established by (CLINICIAN / PSYCHIATRIST): _________________________________________________________________________ |

| |

|ICD-10 DIAGNOSES / DSM IV CODES or DSM IV CODES for Psychiatric Disorder(s): ________________________________________ |

|_____________________________________________________________________________________________________________________________ |

| |

|ICD-10 DIAGNOSES / DSM IV CODES for Substance Use Disorder(s): ________________________________________________________ |

|_____________________________________________________________________________________________________________________________ |

|Mental Health Symptoms (past and present): ________________________________________________________________ |

|______________________________________________________________________________________________________ |

|Current Substance Abuse / Dependence: ___________________________________________________________________ |

|______________________________________________________________________________________________________ |

|History of Violence: ____________________________________________________________________________________ |

|______________________________________________________________________________________________________ |

| |

|Does this potential client have a pending criminal case(s)? Yes No |

|Is this potential client being probation/court mandated to attend treatment? Yes No |

|Does this potential client have a transportation support person for outside appointments? Yes No |

|If yes, please explain and provide supporting legal history/documentation: _____________________________________________________ |

|_________________________________________________________________________________________________________________ |

| |

|Is this potential client mandated by probation/court to attend treatment? Yes No |

|If yes, please explain: _______________________________________________________________________________________________ |

Bonita House, Inc. – Dual Diagnosis Residential Treatment Program

REFERRAL FORM (page 2)

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ADMISSIONS CRITERIA

Potential clients must:

• Be diagnosed with both a severe and persistent psychiatric disorder AND substance use disorder

• Be between the ages of 18

• Be ambulatory and capable of basic self-care

• Be willing to commit to recovery and participate in an intensive, structured treatment program

• Be clean and sober upon admission (i.e. if use occurs just before admission and an individual is NOT in need of medical detox, they are welcomed!)…

• Be able to pay the room & board fee of $912.00/month if using Alameda County Medi-Cal insurance coverage

• Not be a current danger to self or others

• Commit to not smoking cigarettes while in the program

The following is required prior to admission:

➢ Physician’s Report (medical clearance) – completed 30 days or less prior to admit date

➢ TB results – completed 6 months or less prior to admit date

➢ Medication Order (Rx regimen by MD – to include all over-the-counter medications, supplements, herbal remedies, etc.)

➢ 30-day supply of all medications upon admission

Please provide the following for eligibility consideration:

➢ Referral Form (to include ICD-10 Diagnoses & Codes)

➢ Psychosocial / Psychiatric Assessment or Evaluation (to include hospitalizations, legal and violent history, etc.)

Thank you for your interest in Bonita House, Inc.’s Dual Diagnosis Residential Treatment Program. We look forward to serving you!

Kindly,

Crystal Cohagan, LCSW, Admissions Manager

#510.526.4765 x105 (office) / #510.526.2887 (fax)

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