Consumer Referral Sheet

Consumer Referral Sheet

Consumer Name: / Medicaid # if Applicable: / LME Record # if Applicable:

Date of Referral: ______Medicaid County: ______

Date of Birth: ______Sex : ⃞ Male ⃞ Female

Address: ______

City:______State: ______Zip Code: ______

Telephone: (Home) ______(Work) ______(Cell) ______

Referral Source: ⃞ Self/ Referral ⃞ LME ⃞ Hospital ⃞ DSS ⃞ Schools ⃞ Doctor

⃞ Family/Relative/Friend ⃞ Other: List ______

Referral Source’s Name: ______Phone #: ______

Presenting Problems/ Reason for referral:______

______

______

Check all applicable Presenting Problems/ Reason for referral:

⃞Housing/ Residential ⃞ Financial ⃞ Legal ⃞Transportation ⃞Family Conflicts

⃞Emotional / Mental Health Tx ⃞Social Medical/Health Issues ⃞Safety Issues ⃞Day Program

⃞Other(s)

Diagnosis: DSM-IV TR Code and Description and/ or Clinical Impression

Axis I Primary: ______

Axis II Primary: ______

Axis III Primary: ______

Current /GAF Score: ______

Legal Status (Check all that apply):

⃞Competent ⃞ Incompetent ⃞ Minor Denies legal history ⃞ On Probation/Parole

⃞ Juvenile Court ⃞ In Jail ⃞ Legal history/ prior charges (list) ______

Guardianship/ Legally Responsible Person / Emergency Information

Who is the Legally Responsible Party? ⃞ Self ⃞ Guardian ⃞ Parent ⃞ LRP ⃞ Other ______

(Check All that Apply)

Name of Guardian/LRP/Emergency Contact: ______

Address of Guardian/LRP/Emergency Contact: ______

Home#: ______(Work)______(Cell) ______

What services does person currently have, have if any? ______

What services are you requesting? ______

______

(Signature & Title of Person Completing Referral) (Date

Implemented 12/22/2008