930 North 3Rd Street, Grand Forks, ND 58203-2408

930 North 3rd Street, Grand Forks, ND 58203-2408

Phone: 701-795-5056 Fax: 701-772-5560

e-mail: web:

Referral Form

This referral form will remain active for 1 year. A new referral form will need to be submitted after 1 year.

Client Name: New Client Existing Client

Permanent Supportive Housing

Property:Request specific property and occupancy applications from Prairie Harvest Mental

Health Chief Program Officer.

• Placement on waiting list requires BOTH Prairie Harvest Mental Health referral form and Prairie Harvest Mental Health occupancy application.

Supported Residential Services

Send referral to Supported Residential Facilitator.

Representative Payee Services: Provides comprehensive fiscal management to

individuals experiencing difficultymanaging money. *Must have information to process application.

*Mother’s Maiden Name:

*Place of Birth (city, state):

Current Rep-Payee if applicable:

Direct Care: Hours/Week: Direct Care workers guide and support

individuals in independent living skills.

Life Skills Therapy/Job Development: Developsocial, recreational, vocational and leisure

activities with individuals.

Extended Services: Off-site support for employed individuals in the community

Medication Program:SAMS/Med Monitor AM PM AM & PMSAMS only

Consists of self-administered medication program with nurse supervising and monitoring

individuals’ medications.

NEHSC Extended Care Supervisor: Date:

NEHSC Case Manager: Date:

PHMHChief Program Officer: Date:

PHMH Supported Residential Facilitator: Date:

Prairie Harvest Mental Health

Referral Information

Client LegalName: Referral Date:

DOB:SSN:Phone:

Address:

Gender: Male FemaleVeteran: Yes No

* Guardian: Phone:

*Include copy of guardianship papers.

Ethnicity: Hispanic or Latino Non-Hispanic or Non-Latino

Race:

American Indian or Alaskan Native Asian Black or African American

Native Hawaiian or Pacific Islander American Indian/Alaskan Native and White

Asian and White Black/African American and White Other Multi-Racial

American Indian/Alaskan Native and Black/African American White

Financial:

SSI SSDI Social Security

Veterans Benefits Employment Income

Veterans Health Care Medicaid Medicare Food Stamps No Income

Prairie Harvest Mental Health

Referral Information

Dates Most Recent: Physical: Eye Exam:

Dental Exam: Allergies:

Physician:

Pharmacy:

MA #:

Medicare:

Other Medical Insurance:

Psychiatrist:

Emergency Contact Person:

Phone:Address:

Psychological Evaluation: (Include most recent evaluation or the last 6 notes of psych visits.)

Alternative Treatment Order: (Include paperwork regarding ATO)

Social History:(Include most recent hospital and NEHSC admission summaries)

Medications: (Please write down medications or provide a list.)

Special Monitoring Requirements:

Employment History:(Are they currently working? Yes No)

Provide Copy of Recovery/Treatment Plan. Dated:

Revised 10/12/11, 7/7/11, 1/20/12, 8/31/12, 9/26/12, 11/13/12, 5/7/14, 3/3/15lb1