Behavioral Health Referral Form

Behavioral Health Referral Form

Information about Person Completing Referral
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.

Individual Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Individual aware of this Referral?

YesNo
Type of Services Needed

AdultChildAdolescentYouth to Young Transition
Program Needed

Mental Health ClubhouseApex School BasedSystem of CareChild/Adolescent Outpatient ServicesCOVID 19 Intervention ProgramYouth to Young Adult TransitionNone
School Name
Parent/Guardian Name

First NameLast NameRelationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Specify service Individual is considering (Adult)

Case Management (CM)Family Therapy (Mental Health ONLY)Group Therapy (Mental Health ONLY)Individual Therapy (Mental Health ONLY)Intensive Case Management (ICM)Medication Case ManagementPeer SupportsPsychosocial Rehabilitation (PSR)Psychosocial Rehabilitation - Individual (PSRI)Psychiatric Treatment (needs secondary service)Supported Employment (Mental Health ONLY)**Substance Use services
Individual Gender

MaleFemaleOther
Individual Primary Language

EnglishSpanishOther
Reason for Referral
Current Medications
Select all applicable challenges below for the Individual referred (check all that apply)

Ability to avoid dangers/hazardsAngerAnxietyCommunity Linkage of ServicesDaily living skillsDepressionGriefHousingHygieneImpulsive BehaviorsJuvenile Justice/Court InvolvedLife SkillsMaintaining personal affairsMedication EducationNutritionalPhobia/sPRTF/Hospital DischargeSafe living situationSchool behaviorSelf-Advocacy SkillsSelf HarmSeparation IssuesSocial SkillsSubstance UseSustainable employmentTraumaTruancyWhole Health/WellnessYouth to Young Adult TransitionOther
Should be Empty: