Date Received:

Staff Initials:

Bonita House, Inc. – Dual Diagnosis Residential Treatment Program

REFERRAL FORM

*Fax completed form and clinical assessments to 510-526-2887

POTENTIAL CLIENT INFORMATION
DATE of REFERRAL: ______
Name of potential client: Current Living Situation: ______
Address: City: Zip:
Phone: DOB: Age: SSN: Gender:
REFERRAL SOURCE INFORMATION
Name and Title of Referring Person: ______
Referral Type: Self Clinician Psychiatrist Case Manager/Service Team Behavioral Health Care Agency
Referring Agency: ______Phone:
Potential Client’s Psychiatrist: ______Phone:
Conservator/Legal Guardian, if applicable: ______Phone:
PAYMENT INFORMATION Alameda County Medi-Cal Private Pay
Medi-Cal ID#: Date Issued: PSP#:
Does this potential client have a monthly income? Yes No
If yes, what is the source of income? SSI SSDI Other Amount per month, if applicable: $
Payee Name, if applicable: Phone:
ICD-10 DIAGNOSES / DSM V CODES are required for referral review; MUST HAVE both a Psychiatric Disorder AND Substance Use Disorder):
ICD-10 / DSM V DIAGNOSES / CODES for Psychiatric Disorder(s): ______
______
ICD-10 / DSM V DIAGNOSES / CODES for Substance Use Disorder(s): ______
Name / credentials of diagnosing professional and date Dx established:
______
Mental Health Symptoms (past and present): ______
______
Current Substance Abuse / Dependence: ______
______
History of Violence: ______
Does this potential client have a pending criminal case(s)? Yes No
Is this potential client being probation/court mandated to attend treatment? Yes No
Does this potential client have a transportation support person for outside appointments? Yes No
If yes, please explain and provide supporting legal history/documentation: ______
______
Is this potential client mandated by probation/court to attend treatment? Yes No
If yes, please explain: ______

Bonita House, Inc. – Dual Diagnosis Residential Treatment Program

REFERRAL FORM (page 2)

ADMISSIONS CRITERIA

Potential clients must:

·  Be diagnosed with both a severe and persistent psychiatric disorder AND substance use disorder

·  Be 18 or older

·  Be ambulatory and capable of basic self-care

·  Be willing to commit to recovery and participate in an intensive, structured treatment program

·  Be clean and sober upon admission (i.e. if use occurs just before admission and an individual is NOT in need of medical detox, they are welcomed!)…

·  Be able to pay the room & board fee of $927.00/month if using Alameda County Medi-Cal insurance coverage

·  Not be a current danger to self or others

·  Commit to not smoking cigarettes while in the program

The following is required prior to admission:

Ø  Physician’s Report (medical clearance) – completed 30 days or less prior to admit date

Ø  TB results – completed 6 months or less prior to admit date

Ø  Medication Order (Rx regimen by MD – to include all over-the-counter medications, supplements, herbal remedies, etc.)

Ø  30-day supply of all medications upon admission

Please provide the following for eligibility consideration:

Ø  Referral Form (to include ICD-10 Diagnoses & Codes)

Ø  Psychosocial / Psychiatric Assessment or Evaluation (to include hospitalizations, legal and violent history, etc.)

Thank you for your interest in Bonita House, Inc.’s Dual Diagnosis Residential Treatment Program. We look forward to serving you!

Kindly,

Zachary Rosemoore, Admissions Manager

#510.526.4765 x105 (office) / #510.526.2887 (fax)

2 | Bonita House, Inc. – Dual Diagnosis Residential Treatment Program

REFERRAL FORM and ADMISSION CRITERIA