Vera French Community Mental Health Center
Frontier Community Support Program
Referral Form
Date: Referral Source:
Name: Social Security Number:
Address: DOB: Age:
City/State/Zip: Phone Number:
Insurance Information, Source and Number:
Financial Information, Source and Number:
Legal Settlement: County: State: Undetermined: Committed: Yes No
Eligibility Criteria:
Yes No The client referred;
shall be a person with a chronic mental illness.
is able to benefit from and desires at least one component of the FCSP, based on a psychiatric/functional assessment.
has undergone psychiatric treatment more intensive than outpatient care more than once in a lifetime; e.g.
ER, Day Treatment.
has experienced a single episode of continuous structured supportive residential care other than
hospitalization.
Yes No The client referred must need assistance in at least two of the following areas. Does the client:
have markedly limited work skills, a poor work history, employed in a work shelter or currently
unemployed?
require financial help for community living and need assistance to obtain this?
show severe inability to establish or maintain a personal support system?
Require help in basic living skills?
Exhibit inappropriate social behavior that results in intervention by the mental health or judicial system?
Eligible? Yes No Staff: Date:
Diagnosis: Please complete and include physical as well as psychiatric information.
Axis I:
Axis II: Axis III:
Axis IV: Current GAF:
Physician: Nurse:
Medication, dose and frequency:
Allergies:
Additional Comments:
Referral Materials: Please provide all that are available.
ICP Assessment Social History Psych. Evaluation Releases Treatment Goals
Emergency Contact: Phone Number:
Name: Relationship:
Address: City/State/Zip:
(Continued on Reverse Side)
Medication Management (separate referral required)
Medication Education
Symptom Recognition
Money Management (separate referral required)
Grocery Shopping (separate referral required)
Adult Daily Living Skills
Outreach Referral source requests that FCSP provide services in the client’s home or in the community.
Assistance/Referral
Housing/Living Arrangements
Mental Health Treatment
Problem Solving
Group Therapy
Crisis Intervention
Rehabilitation
Socialization
Communication Skills
Stress Management
Personal Hygiene
Recreation
Family and Community Support
Family Involvement
Coordination and Development of Natural Support System
Protection and Advocacy
Service Coordination
Drop In Only
Referral source expects client to attend FCSP without participating in specific program components.
Signature of Referral Source: Date:
Signature of FCSP Staff: Date: