North Carolina Referral Form

Referral For:*

PSR / Psychosocial RehabilitationACT / Assertive Community Treatment Team

Client Name*

Date of Birth:*

Date

Social Security #*

Phone #*

Area CodePhone Number

Current Address/City/State/Zip*

Guardian/Emergency Contact Name

Guardian/Emergency Contact Phone #

Housing:*

Race

Ethnicity

Gender

Primary Language Spoken

Special Accommodations

Physical DisabilityInterpreterOther

Type of Insurance*

MedicaidMedicareNone

Medicaid #

Medicare #

Date & Location of Last Hospitalization

Date / Location

Number or SA Outpatient Commitment?

Number or Yes / No

Diagnosis

Please Check Appropriate Boxes

Difficulty managing moods, emotions, behaviors and/or anxiety due to mental illness, recent loss or other circumstance impacting daily functioningDifficulty performing practical daily living tasks required for basic adult functioning or significant support or assistance is needed from others to perform these tasksDifficulty maintaining consistent employment at a self-sustaining level or carrying out the homemaker role (e.g. preparing meals, washing clothes, budgeting or child care responsibilities)Difficulty maintaining a safe living situation (e.g. repeated evictions or loss of housing)High use of acute psychiatric hospitalizations or psychiatric crisis emergency servicesPersistent or recurrent major psychiatric symptoms (e.g. affective, psychotic, suicidal)Difficulty meeting basic survival needs, residing in substandard housing, homelessness or imminent risk of becoming homelessCoexisting mental health and substance abuse disorder of significant durationHigh risk of recent history of criminal justice involvement (arrests or incarcerations) DUI and Suspended License

Referring Clinician*

Referring Clinician Email*

example@example.com

Referring Entity*

Contact Information:

Together House- Evelyn Cooke ecooke@pms-corp.net 336-513-4229

Greensboro ACT - Abby Owenby aowenby@pms-corp.net 336-834-9664

Psychotherapeutic Services of North Carolina Online Referral Form

Patient Information

Insurance Information:

Hospitalization History:

Reason For Referral: