CENTER HOUSE DAY TREATMENT PROGRAM
REFERRAL FORM
Please complete and return this form to:
e-mail:
fax: 617-523-7618
mail: 31 Bowker St., Boston, MA02114
Please call 617-371-3020 if you require more information.
Date of Referral:
Contact Information:
NAME:TELEPHONE
ADDRESS
D.O.B.: SEX:MARITAL STATUS
INSURANCE: Card Number (RID#):
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Referral Source(Name, Phone, Address):
Relationship to Client:
Discharge date from current service (if applicable):
Other referrals being made(e.g. clubhouse, vocational services, DMH etc.):
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Treatment/Professional Contacts:
Psychiatrist/ Prescribing Physician or Nurse:(Name, Agency, Phone):
Therapist: (Name, Agency, Phone):
Case Manager: (Name, Agency, Phone):
CSP or CBFS worker: (Name, Agency, Phone):
P.C.P.: (Name, Agency/Clinic, Phone):
Other treatment contacts: (Name, Agency, Phone, Relationship to client):
Legal Guardian? Yes No If yes, name, phone/email, relationship to client:
Diagnostic Information:(please list all diagnoses with ICD10 codes)
GAF:
Current Medications (include dosage)
Income Source (salary, family, disability income, etc.)
Living Arrangements (group home, alone, w/family, etc.)
Please describe Reason for Referral/ Treatment Goals relevant to Day Treatment :
Psychiatric symptoms (check all that apply):
Depression Positive Sx of Psychosis Dissociative Sx
AnxietyNegative Sx of Psychosis Emotional Dysregulation
ManiaOCD Sx Sleep Disturbance
Self-injurious behaviors Suicidal ideation Homicidal ideation
Please elaborate on any box checked:
History of Psychiatric Treatment & precipitants to hospitalization: (include inpatient and outpatient, please include dates):
Risk Assessment:
Hx of suicidal ideation Hx of homicidal ideation Hx of violence
Hx of suicide attempts Hx of psychosis Verbal aggression
Hx of tx non-compliance Hx of fire setting Family violence Medical risk issues
Please elaborate on any box checked:
Alcohol/ Drug Use History & Substance Abuse Treatment History:
Longest period of sobriety:
Current length of sobriety:
History of abuse/trauma:
Current or History of Disordered Eating Behavior (i.e. restricting food intake, bingeing, purging or other compensating behaviors)
Medical History (Please include significant illnesses, conditions, any ongoing physical illnesses):
Current or History of involvement with Criminal Justice system (Please include any Arrests, Incarcerations, Court orders, names of parole officers, etc.)
Current probation issues (if applicable):
Educational and Occupational History (highest grade completed; competitive, sheltered, volunteer work):
Has this person ever served in the military? YES NO
(if yes, in what capacity/current military status?):
Family Relationships and Social Supports :
Cultural/religious background/ Sexual orientation
Client strengths/ Additional Referral Information
Name of Referral Source
Signature of Referral Source
Agency and Telephone Number
To set up INTAKE interview, please contact (check box):
Referral Source Client
CHDTP ReferralRevised 9/20161