Referral for Psychiatric Rehabilitation Program

Psychiatric Rehabilitation Program Referral

To efficiently process referrals, please fill out this form in its entirety, sign, and date.
Date

MonthDayYear
Date
Consumer Name:
SS#
DOB:
Sex:
Race:
Street Address:
Phone (Home)
(Work/Mobile)
Physical Description:
Highest Grade Completed:
Emergency Contact (Relationship to Consumer)
Contact's Phone (Home):
(Work/Mobile):
Support for Client?

YesNo
Current consumer status (please indicate to assist in the prioritization of referrals):
Inpatient-projected release date:
Partial Hospitalization-projected release date:
Crisis Bed/ Other crisis facility-projected release date:
Click for:

Outpatient
Date of most recent inpatient discharge:
Other:
DSM 5 Behavioral Diagnosis: Code(s) Priority Pop. DSM-5/ ICD-10 Behavioral Diagnosis: (Consumer MUST have one of these diagnosis as primary to qualify for services

295.90/F20.9 Schizophrenia295.40/F20.81 Schizophreniform Disorder295.70/F25.0 Schizoaffective Disorder, Bipolar Type295.70/F25.1 Schizoaffective Disorder, Depressive Type298.8/F28 Other Specified Schizophrenia Spectrum or Other Psychotic Disorder298.9/F29 Unspecified Schizophrenia Spectrum of Other Psychotic Disorder297.1/F22 Delusional Disorder296.33/F33.2 Major Depressive Disorder, Recurrent Episode, Severe296.34/F33.3 Major Depressive Disorder, Recurrent Episode, Severe with Psychotic Features296.43/F31.13 Bipolar I Disorder, Current or most Recent Episode Manic, Severe296.44/F31.2 Bipolar I Disorder, Current or most Recent Episode Manic, Severe, with Psychotic Features296.53/F331.4 Bipolar I Disorder, Current or most Recent Episode Depressed, Severe296.54/F31.5 Bipolar I Disorder, Current or most Recent Episode Depressed, Severe with Psychotic Features296.40/F31.0 Bipolar I Disorder, Current or most Recent Episode Hypomanic296.7/F31.9 Bipolar I Disorder, Unspecified296.80/F31.9 Unspecified Bipolar and Related Disorder296.89/F31.81 Bipolar II Disorder301.22/F21 Schizotypical Personality Disorder301.83/F60.3 Borderline Personality Disorder
Additional Behavioral Health Diagnosis:
Primary Medical Diagnosis:
Elements Impacting Diagnosis: (check all that apply)

NoneProblems with access to healthcare servicesHousing problems (Not Homelessness)Problems related to social environmentEducational problemsProblems related to interaction w/ legal system/crimeOccupational problemsHomelessnessFinancial problemsProblems with primary support groupOther psychosocial and environmental problemsUnknown
Functional Assessment:
Definition of Problem Areas (Current Symptoms)
Reason(s) for seeking treatment (check all that apply)

Linkage to community resources/community integrationFacilitating transition from more intensive servicesPrevention/reduction of hospitalization or rehospitalizationCoordination of current community services
Other:
Risk for Aggressive Behaviors, Suicide, or Homicide (explain):
Entitlement Information:
SSI monthly: $
Date Active:
SSDI monthly: $
Date Active:
Medicaid #:
Date Applied/Active
Other Income/Insurance:
If consumer does NOT have medical assistance/Medicaid, he or she must meet one of the following criteria to qualify for services through Uninsured Eligibility Coverage

Has been incarcerated within the last three (3) monthsCurrently homeless or at risk for homelessnessHas had an inpatient hospitalization within the last three (3) months
Upon the clinician's signature below, the consumer being referred is appropriate for psychiatric rehabilitation program services provided by People Inspiring People. This referral must be signed by a physician, nurse practitioner, or independently licensed clinician
I, (Clinician's Signature)
Clinician's Name and Credentials
(Clinician's Phone Number)
(Clinician's Email)
example@example.com
Refer, (Print Consumer's Name)
Should be Empty: