Psychosocial Rehabilitation Referral
Client's Name:
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Do you have Medicaid?
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Please Select
YES
NO
Medicaid Number
Individual must meet two of the following criteria on a continuing or intermittent basis:
Experience difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of psychiatric hospitalization, homelessness, or isolation from social supports.
Experience difficulty in activities of daily living, such as maintaining personal hygiene, preparing food and maintaining adequate nutrition or managing finances to such a degree that degree that health or safety is jeopardized.
Exhibit such inappropriate behavior that repeated interventions documented by the mental health, social services, or judicial system are or have been necessary; or
Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or significantly inappropriate social behavior. "Cognitive" is defined as the individual's ability to process information, problem-solve and consider alternative, it does not refer to an individual with an intellectual or other developmental disability.
Individual must meet one of the following criteria
Have experience long term or repeated psychiatric hospitalization; or
Experienced difficulty in activities of dialy living and interpersonal skills or,
Have a limited or non-existent support system; or
Be unable to function in the community without intensive intervention; or
Require long-term services to be maintained in the community
Diagnosis/Presenting Issues
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Referring Person/Agency
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Referral Source Contact Number
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Please enter a valid phone number.
Signature:
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Today's Date
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Month
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Day
Year
Date
Submit
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