Referral Form

The STRENGTH Program

Psychiatric Rehabilitation Program Referral Form
Patients Name*

First NameLast Name
Sex:

Gender Identity
D.O.B.
Age
Medical insurance Policy Number
Social Security Number
Phone Number*
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState

Zip
Email
example@example.com
Alt Number
Elementary SchoolMiddle SchoolHigh SchoolSome CollegeCollege Graduate
Employment History
Does the Parent/Guardian have legal custody of the minor?
If patient is an adult, do you/they have a legal guardian? If yes, provide guardian information
Please provide parent/custodial information
Name

First NameLast Name
Phone
Format: (000) 000-0000.
Address (leave blank if same as client)

Address

Street Address Line 2

CityState

Zip
Coping SkillsAssertivenessAdult Vocational/Educational SkillsSocial Skills/Peer InteractionSelf-Esteem Behavior InterventionsSchool PerformanceOther
DSSDJSParole & ProbationOther
Involved Agency Contact Name
Phone
Format: (000) 000-0000.
Email
example@example.com
For Clinician Only:
Diagnosis:

ICD 10 CodeDescription
Diagnosis:

ICD 10 CodeDescription
Diagnosis:

ICD 10 CodeDescription
Diagnosis given by:
Name and Credentials
Date

MonthDayYear
Current Medications:
Please provide name and dosage
Current clinical state and justification for PRP services:
Referral Source:
Current Outpatient Agency
Clinician Name and Credentials
Clinician NPI#
Phone
Format: (000) 000-0000.
Clinician Email
example@example.com
Clinician Signature
Today's Date

MonthDayYear
Date
Should be Empty: