ARMHS REFERRAL FORM
Referred by & Relationship
Agency & Address
Contact Number
*
Email Address
FAX
Client Information
Full Name
*
Date of Birth
*
-
Month
-
Day
Year
MA Number
Race/Ethnicity
Contact Number
*
Email Address
Address
Gender
*
Male
Female
Non-binary
Other
Is this individual their own guardian?
*
Yes
No
Is this individual aware of this referral?
Yes
No
Day treatment or work schedule?
Yes
No
Please enter work schedule
Client availability - day(s):
Monday
Tuesday
Wednesday
Thursday
Friday
Client availability - time(s):
Morning (8AM - 12PM)
Afternoon (12 - 4PM)
Evening (4 - 7PM)
Is this individual open to telehealth services?
Yes
No
Does this individual l have a staff preference?
Male
Female
No Preference
Has this individual received ARMHS in the past?
Yes
No
Provider
Date(s)
Mental health information
Mental health diagnosis(es)
*
Major depression
Bipolar disorder
Borderline personality disorder
Schizophrenia
Schizoaffective disorder
If any other
Psychiatrist and clinic
Phone
FAX
Address
Therapist and clinic
Phone
FAX
Address
Do you have mental health records for this individual?
*
No
Yes
If Yes, please upload
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ARMHS goals for this individual
interpersonal communication
Crisis assistance
Relapse prevention
Medication monitoring
Community integration
Budget/shopping/lifestyle skills
Mental illness symptom management
Household management
Transitioning to community living
Employment related skills
Any additional notes
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