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Referral Form

CLIENT INFORMATION

First Name

*

Last Name

*

Gender

*

Male

Female

Date Of Birth

*

Age

*

Address

*

City

*

Zip

*

Phone number

*

Parent/ Guardian

*

Relationship to client

*

Alt #

School

*

Grade

*

Language

*

Is an Interpreter required

*

No

Yes

Is the client aware of this referral

*

No

Yes

REFERRING SOURCE

Agency

*

Name

*

Phone

*

Fax

Email

*

Best Method, Day, and Time to Contact:

*

PRIMARY CARE PHYSICIAN:

Name

*

Phone

*

Fax

Presenting Problems: (symptoms, duration, severity, contributing factors)

*

Referral Reason:

*

CLINICAL FEATURES (Pre-Screening Assessment)

1. Suicidality/Self-Harm Behavior:

Ideation:

*

No

Active

Passive

Plan:

*

No

Yes

Atteempts:

*

No

One

More than one

Date of last attempt:

2. Aggressive Behavior:

Towards others? :

*

No

Yes

Towards property? :

*

No

Yes

3. Legal Charges/Involvement:

Are you aware?

*

No

Yes

4. School Issues (Suspensions or Academic Problems)

*

5. Functional Concerns: (self-care/hygiene, making friends, cleaning, daily activities)

*

6. List other involved care providers: (Psychiatrist, MH worker, Counselor, Therapist, etc.)

*

7. Current Medication List (attach documentation)

Size limit: 10 MB

8.Current or Past Diagnosis

*

9. Previous Psychiatric Involvement (attach documentation):

Presenting Problem

Dates

Hospitalised?

10. Substance Use (alcohol & drug):

Current use

Past use

11. Medical issues

*