HOLISTIC HEALTH ADVANCEMENTS, LLC
Referral Application
Date
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Month
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Day
Year
Date
Date Placement Required
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Month
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Day
Year
Date
RESIDENT INFORMATION
Full Name
Social Security Number
Alias if applicable
Medicaid Number
Date of Birth
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Month
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Day
Year
Date
Age, Sex, Weight, Height, Religious Affiliation:
County of Legal Custody
Place of Birth
Strengths:
Strong Family Base | Appropriate Reading Level | Good Personal Hygiene | Average/Above IQ | Impulse Control | Good Social Skills | Good Verbal Skills | Appropriate Coping Skills |Other:
Distinguishing Features (scars, tattoos, birthmarks, etc:
Weknesses:
Functionally Illiterate | Weak Family Base | Low IQ | Poor Personal Hygiene | Poor Social Skills | Other:
MEDICAL INFORMATION
Diagnoses
DSM V / ICD-10 Diagnosis:
Diagnosis Date
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Month
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Day
Year
Date
Source
IQ Score
Verbal
Performance
Full Scale
Examiner
Date
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Month
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Day
Year
Date
Level of Education LOE
CAFAS Score
GAF Score
Medications
Dosage | Instructions | Prescriber
Allergy Information - Allergen Type (Medical, Environmental, Food, Other) Reaction/Response
Medical | Environmental | Food | Other
Medical History (Past & Present)
Asthma ☐ Diabetes ☐ Seizures ☐ Tuberculosis ☐ HIV/AIDS ☐ Anemia ☐ Migraines ☐ SickleCell Anemia☐ Eating Disorder ☐ Drug/Alcohol Abuse ☐ Skin Conditions ☐ Sinus Problems ☐ Convulsions☐ Lice☐ Bulimia ☐ Anorexia ☐ Measles ☐ Hay Fever ☐ Mumps ☐ Chicken Pox ☐ Sexually Transmitted Diseases☐ Ringworm ☐ Eczema ☐ Other:
Last Physical Exam
Last Dental Exam
Last Eye Exam
Medical Insurance Provider
Policy Number
Primary Insured Name
Special Dietary Needs
Mental Health History
Previous Mental Health Treatment
Treatment Type | Facility/Provider | Dates of Service
Educational Information
Last School Attended
School District
Grade Level
Special Education Services: EH LD Resource Homebound Other:
Truancy History
Yes
No
Grades Repeated
Suspensions | Expulsions
Agency Involvement:DSS AMH DJJ Vocational Rehab Other:
PRIMARY REFERRAL SOURCE
Referring Agency: OJJ AMH DSS MCO Other:
Case Manager Name
First Name
Last Name
Case Managers Name
First Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Reason for Referral
CURRENT BEHAVIORAL CHALLENGES
Please explain any of the following:
Anxiety | Arson | Alcohol/Drug Abuse | Assaultive (Physical, Verbal, Sexual) | Depression |Developmental Disability | Homelessness | Impulsivity Lying | Self-Harm | Truancy | Suicidal Ideation | Oppositional Defiance | Cruelty to Animals | Running Away Other:
History of Abuse Explain
Family Information
Parent/Guardian Information
Biological Mothers Name
Address
Phone Number
Format: (000) 000-0000.
Race
Education Level
Biological Fathers Name
Address
Phone Number
Format: (000) 000-0000.
Race
Education Level
Married Separated Divorced Never Married DeceasedParental Rights Terminated? Yes No I If yes, when?
If yes when
Number of Siblings
Are siblings in out-of-home placement? Yes NoIf Yes, specify: DSS | Foster Care | Relatives Incarcerated | Residential
Yes | No: If Yes, specify: DSS | Foster Care | Relatives Incarcerated | Residential
Document Upload Section
Please attach the following required documents:
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Person-Centered Plan | Comprehensive Clinical Assessment | Service Order | Physical Health Assessment | Other
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