Referral Form

REFERRAL FORM
REFERRAL SOURCE
Name of Person Referring:*

First NameLast Name
Phone Number:*

Area CodePhone Number
Relationship to Client:*
Referral Source:*
Referral Date:*

MonthDayYear
Time of Referral:

:HourMinutesAM/PM Option
NATURE OF REFERRAL
Emergent: 2 HoursUrgent: 48 HoursRoutine: 7 Days
YESNO
YESNO
YESNO
YESNO
1. Care Was Provided is defined as follows: The person had a face-to-face service (assessment and/or treatment) within the required target time frame. The time period is measured from the time that the 911 call or call to the LME’s Access Unit/Service was received, or if the person was a walk-in, from the time that the person was determined to need this level of care.

2. Access Was Available But Not Seen is defined as follows: Access to face-to-face care was available within 2 hours of requesting services, but the person did not receive a face-to-face service within this time frame because the person was not available. Access is defined as having a qualified provider on the physical premises ready to provide immediate care as soon as the consumer is available to receive care.

3. Offered But Declined Appointment is defined as follows: The consumer was scheduled for an appointment for the appropriate level of care within the required target time frame but later called and rescheduled the appointment to a later date/time, or the consumer was offered one or more appointments at reasonable times within the target time frame but declined the appointment for personal convenience or necessity that it should be scheduled at a later time.

4. Scheduled Within 7 Days Of Request But Did Not Show is defined as follows: The consumer was scheduled for an appointment for the appropriate level of care within the required target time frame but did not show up for the appointment.
CLIENT PERSONAL INFORMATION
Client Name:*

First NameLast Name
Client's Birth Date:*

MonthDayYear
YESNO
If yes, name of Insurance/ Policy Number:*
YESNO
CLIENT PERSONAL INFORMATION
Client's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Client's Phone Number:*

Area CodePhone Number
Guardian/Next of Kin:*
Guardian/Next of Kin's Phone Number:*

Area CodePhone Number
EMERGENCY CONTACT
Emergency Contact Name:*

First NameLast Name
Relationship:*
Client's Emergency Contact Phone Number:*

Area CodePhone Number
PRESENTING PROBLEM OR NEED
Intellectual Development DelayedMental HealthSubstance Abuse
Diagnosis:
Briefly explain the client's current problem or need: *
Describe any pertinent past information we should know:
PROPOSED SERVICE DELIVERY TO MEET PROBLEM OR NEED
Diagnostic Assessment/ Substance Use EvaluationMH Therapy (Indiv., Family, Group)Substance Use Counseling (Indiv., Or Group)Early Intervention Level 0.5Outpatient Treatment Level 1DUI Education ProgramPsychiatric Rehabilitation Program (C/A or Adult)Medical AppointmentOther
Other relevant Information:
Include other information discussed during referral that could assist in PCP planning:
Signature:*

Clear
Date:*

MonthDayYear
Date
Privacy Statement

Changing Lives Adult & Youth Services, LLC. values your privacy and assures you we will never give or sell your personal information to any third parties. All personal information you provide on our web site (i.e.: name, address, email address and telephone number) will be kept confidential and will only be used to provide services with Changing Lives Adult & Youth Services, LLC. Changing Lives Adult & Youth Services, LLC. who are given access to your personal information will be required to keep the information confidential and not use it for any other purposes other than the services they are performing forChanging Lives Adult & Youth Services, LLC
Should be Empty:

REFERRAL FORM

REFERRAL SOURCE

NATURE OF REFERRAL

CLIENT PERSONAL INFORMATION

CLIENT PERSONAL INFORMATION

EMERGENCY CONTACT

PRESENTING PROBLEM OR NEED

PROPOSED SERVICE DELIVERY TO MEET PROBLEM OR NEED