DC Recovery Academy
Referral Form
The DC Recovery Academy is now certified by the Department of Behavioral Health as a Specialty Provider to provide Mental Health Rehabilitation Day Services. This is the new referral form that we request all CSAs use when referring a client to this service. With certification our focus has not changed. We are serving young adults, aged 18-35, with a goal of work or school. However, we can serve individuals older than 35 as long as they have a goal of work or school. Please complete this referral and fax it with the following documents:
___Copy of the Diagnostic Assessment
___Copy of the IRP with Rehabilitation Day (or DC Recovery Academy) included as an objective
Please make sure the referral form includes the client’s Medicaid number and whether he/she is enrolled in a MCO. Also include whether the client is receiving ACT services with the CSW contact so that services can be coordinated. ACT cannot be billed the same day Rehabilitation Day is provided.
Please fax all referrals and attachments to the DC Recovery Academy
Attention: Casey Quigley, DC Recovery Academy Manager
(202) 373-0898
Please follow up the fax with an email to
Or a phone call to (202) 373-0800
D.C. Recovery Academy
Referral Form
Client Name:______Date:______
Address:______Referring CSA:______
______Staff Name:______
Phone:______Staff Phone:______
Date of Birth______Staff Cell:______
SSN______Email:______
Is client an ACT client? ___Yes___NoIs client receiving supported employment? ___Yes ___No
Medicaid #______Medicaid MCO______No Medicaid _____
Presenting Problem______
______
Is client interested in___ work ___ school
Transportation Needs:______
Are there language barriers? ___ yes ___ no
Are there literacy issues? ___ yes ___ no
Does client have a substance abuse history? ___ yes ___no If yes, when was the last use and substance used?______
Does client have a legal history? ___ yes ___no If yes, when was the last arrest and what was the charge?______
______
Provide individual’s criminal history including: Type of Offense, Date of Offense and Jurisdiction______
Current Criminal Justice Status: ___Probation___Parole___Charges Pending
Doesclient have a suicide history? ___ yes ___no If yes, when was the last attempt?______
D.C. Recovery Academy
Does client have a history of self-harm? ___ yes ___no If yes, please describe the last attempt and frequency______
______
Doesclient have a history of violence? ___ yes ___no If yes, when was the last violent incident? Identify triggers that result in violence:______
When was the client last hospitalized for psychiatric reasons?______
Where?______
Please briefly state the type of employment in which the client is interested:______
Please briefly state past work experience:______
Doesthe client have legal documents to work in the US? ___ yes ___no
Does the client have an Advanced Directive? ___yes ___no (if yes, please provide copy)
______
Staff Signature
Attach the following forms:Diagnosis (MH & C0-occurring disorders)
Medication
Diagnostic Needs Assessment
IRP reflecting DC Recovery Academy
Fax Completed Form and Email Notification to:
Casey Quigley
Manager of the D.C. Recovery Academy
Fax: (202) 373-0898
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