• Assertive Community Treatment (ACT) Referral

  • In order to make a program referral, please complete all required sections below:
  • Who is completing this referral?*
  • Pronouns
  • Do you currently have a phone?*
  • Format: (000) 000-0000.
  • Current living situation (please select one)*
  • Preferred mailing address (where would you like to receive mail)*
  • Preferred method of contact (select all that apply)*
  • Best time to contact you*
  • Demographics
  • Primary spoken/written language
  • Race (select all that apply)*
  • If Hispanic/Latino, please specify (optional)
  • Income Source (select all that apply)*
  • Current Housing Status*
  • Which benefits do you currently receive (select all that apply)
  • Insurance Type (select all that apply)*
  • Insurance provider/managed care organization (if any)*
  • Reason for Seeking Services
  • What support are you currently looking for?*
  • Mental Health Information
  • Have you ever been told by a psychiatrist, therapist, psychologist, or other mental health professional that you have a mental health diagnosis?*
  • If yes, what mental health diagnosis have you been told you have? (if you know)*
  • Have you been told you have any other mental health diagnoses?*
  • If yes, what mental health diagnosis have you been told you have? (if you know)*
  • Alcohol or Drug Use
  • Do you currently use alcohol or other substances, or have you used them in the past?*
  • If yes, please select any substances that apply (select all that apply)*
  • Emergency Contact Information
  • Format: (000) 000-0000.
  • Can we contact this person regarding your care?*

  • PLEASE EMAIL ACT-ILLINOIS@NYAP.ORG IF YOU HAVE ANY QUESTIONS

  • Referral Source Information
  • Role/Relationship to Person Served*
  • Format: (000) 000-0000.
  • Is the person served aware that this referral is being submitted?*
  • Is there a Release of Information (ROI) allowing communication with your agency/provider?*

  • Person Served Information

  • Pronouns
  • Do they currently have a phone?*
  • Format: (000) 000-0000.
  • Current living situation*
  • Primary spoken/written language
  • Race (select all that apply)*
  • If Hispanic/Latino, please specify (optional)
  • Income Source (select all that apply)*
  • Current Housing Status*
  • Which benefits does the person served currently receive (select all that apply)
  • Insurance Type (select all that apply)*
  • Insurance provider/managed care organization (if any)*

  • Reason for Referral

  • Reason for Referral (select all that apply)*
  • Mental Health Information
  • Has the person served ever been diagnosed with a mental health condition by a psychiatrist, therapist, psychologist, or other mental health professional?*
  • If yes, primary mental health diagnosis (if known)*
  • Additional mental health diagnosis (if known)*
  • Does the person served currently use alcohol or other substances, or have they used them in the past?*
  • If yes, select substances that apply*
  • Current Behavioral Health Services
  • Is the person served currently receiving behavioral health services?*
  • Services received*
  • Psychiatric History (if known)
  • Has the person served experienced psychiatric hospitalization?*
  • Number of psychiatric hospitalizations in the past year (if known)*
  • Current Risk Concerns
  • Does the person served have current concerns related to:*
  • Emergency Contact Information
  • Format: (000) 000-0000.
  • Can we contact this person regarding the care of the person served?*

  • PLEASE EMAIL ACT-ILLINOIS@NYAP.ORG IF YOU HAVE ANY QUESTIONS

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