3. List of Current Medications, Dosages and Frequency

3. List of Current Medications, Dosages and Frequency

Referral Agency:
Contact: / Phone:
Email Address:

1. Basic Consumer Information:

Name: First: / M.I.: / Last:
Date of Birth: / Race/Ethnicity: / SS#
Gender: / Marital Status:
Phone number where Consumer can be reached:
Best Time(s) To Reach?
Residential Address: / County:
City: / State: / Zip Code:
Emergency Contact: / Relationship:
(Name)
Phone (Day): / Evening

2. Psychiatric History:

Primary Disability: / MH / MR/DD IDD / SA
Diagnosis: / Primary
Secondary

3. List of current medications, dosages and frequency

A. / D.
B. / E.
C. / F.
If Consumer receives a IM injection give date of last injection:
Any PRN medications in the last 30 days (Describe)?
Date of last PPD: / Results: Positive Negative

4. Community Care Provider Involvement:

Active / Inactive / Local Provider E-Mail:
Local Provider Name: / Phone Number:
Primary Contact: / Phone Number:

5. Psychosocial Stressors/Events(check all that apply)

Recent Death / Recent Hospitalization
Physical/Sexual/Emotional Abuse / Legal Issues
Relapse/De-compensation / Financial Difficulties
Homelessness
Describe Other:
Recent History of Danger to Self/Others: / Suicidal / Homicidal / Aggressiveness
Behavioral Evidence:
Date of most recent behavioral concern:

6. Admission Criteria(check all that apply):

A. Hospitalization/CSU/Jail/Prison
Transitioning from psychiatric inpatient setting or Crisis Stabilization UnitsChoose an item.
3 or more Hospitalizations within the past 12 months or extended hospital stay of 60 or more days within the past 12 months UnitsChoose an item.
Location of Hospitalization/CSU Date
1. 1.
2. 2.
3. 3.
Recent released from Jail or Prison. Choose an item.
Name of the Jail or Prison.
B. CRA criteria:
  1. High use of acute psychiatric hospitals (e.g. three or more admissions per year) or extended hospital stay (45 days within the past year) or psychiatric emergency services.

  1. Intractable (i.e. persistent or very recurrent, severe major symptoms (e.g. affective, psychotic, suicidal).

  1. Coexisting substance use disorder of significant duration (e.g. greater than six months) or Co-diagnosis of substance abuse (ASAM Levels I, II.1, II.5, III.3, III.5).

  1. High risk or a recent history of criminal justice involvement (e.g. arrest and incarceration).

  1. Residing in an inpatient bed or in a supervised community residence, but clinically assessed to be able to live in a more independent living situation if intensive services are provided, or requiring a residential or institutional placement if more intensive services are not available.

  1. Chronic Homelessness- One continuous year of homelessness or 4 episodes within the past 3 years. Choose an item.
  1. Client is free from medical issues that require daily nursing or physician care.
Choose an item.
8. Client can safely remain in an open, community-based placement
Choose an item.
9. Client demonstrates need for short-term crisis support to prevent recurrence of
hospitalization or to transition back to community from hospitalization
Choose an item.
In the space below provide complete behavioral evidence for primary symptoms/behaviors checked above:

7. Legal History:

A. Supervision Needs: / Yes No / Rational:
Expiration Date:
Forensics conditional release / Yes / No
B. Current Charges (Explain circumstances below):
C. Hearings/trials pending: / Yes / No
Dates to be included:
D. Probation/Parole Officer name:
Phone Number: / Email:
E. Conditions of Probation/Parole:
F. Is there a required level of supervision? (Describe):

8. Financial History:

A. Amount(s) (check all that apply)
SSI / VA / Medicare
SS / Medicaid / Health Insurance Subscriber
Funds in Hospital Account / If checked, amount$
B. Guardian: / Yes / No
Name:
Address:
City: / State: / Zip Code:
Phone Number:
C. Representative Payee: / Yes / No
D. Legal Guardian Payee: / Yes / No
E. Legal guardian documentation attached: / Yes / No

9. Employment History:

Employed: / Yes / No
Name of Company:
Address of Company:
City: / State: / Zip Code:
Length of employment:
Name of Insurance Company:
Group Number: / Policy Holder:

Upon completion, please fax this referral form along with supporting records such as; Psychiatric Evaluation, Psycho-social Assessment and History, Physical,and 30 days of progress noteswith this document to 678-784-1515

(For Office Use Only)

Date Referral Received:
Received By:
Reviewed By:
Disposition:

CRA/TRANSITIONAL HOME REFERRAL FORM 9-2017Page 1 of 4

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