Behavioral Health Referral Form

Behavioral Health Referral Form
- Name
  
  First NameLast Name
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- 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.Format: (000) 000-0000.
- 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: