EASAPROGRAM-REFERRALFORM
County of Residence: Agency Name:Prime#:
Staff Name: Client ID #:
Client Name: Referral Date:
Referral Year:QTR1-Jan-MarQTR2-Apr-JunQTR3-Jul-SeptQTR4-Oct-Dec
Client Demographics
Date of Birth:Unknown (age if DOB isunknown)
Client Identified Race: (check all that apply)
Alaska Native
American Indian
Black or African American
White
Asian
Native Hawaiian or Other Pacific Islander
Other Single Race (specify)
Unknown
Client Identified Ethnicity: (check all that apply)
Not of Hispanic Origin
Mexican
Puerto Rican
Cuban
Other Specific Hispanic(specify)
Hispanic – Specific Origin not Specified
Unknown
Gender:
Female
Male
Other (specify)
Unknown
Living situationonreferraldate:
Independent: client (+partner) responsible for all housing costs (their portion if roommates)
Semi-Independent: client contributes to housing costs and family provides the rest
Family provides housing: lives apart from family (family pays client's housing costs)
Family provides housing: lives with family or foster family
Institution: Hospital, Jail, Juvenile Detention etc.
Homeless (no permanent address)
Residential Treatment Center or Group Home
Other (specify)
Unknown
PrimaryLanguage:
English
Spanish
Other (specify)
Unknown
Country of Origin:
USA
Mexico
Other (specify)
Unknown
If Country of Origin is not USA how many years has client lived in USA?
Under 5 years
Over 5 years
Unknown
ReferralInformation
Howwastheclient/familyreferred?
(Individualwhocalled inthe referralorencouraged family orindividualto call.)
Medical Provider
School, Staff or Liason
Outpatient Mental Health Provider(same agency as EASA)
Outpatient Mental Health Provider (different agency than EASA)
Crisis System / Emergency Department
Psychiatric Hospital
Family, Friend or other Natural Support Person had prior knowledge ofEASA
Advocacy Group
Clergy
Information and Referral Line or Crisis Line
Internet search led to EASA website
Justice System
Media
Public Presentation
Residential Treatment
Social Services Provider
Vocational Rehabilitation
Other (specify)
Unknown
Is this the referent's first referral to EASA?
Yes
No
Unknown
ReferralDecision
Decision Date:Person Making Decision:
Screened In (check and select the choice below that contributed most to the acceptance)
First episodepsychosis, within 12 months(number of months )
First episodepsychosis, greater than 12 months by exception(number of months)
Symptoms consistent with Psychosis Risk Syndrome
Further Assessment needed to assess appropriateness
Familyhxwithdecline
Other Reason (specify)
______
Screened Out (check and select the choice below that contributed most to the rejection)
NoSymptomsofPsychosis
IQ under70
Age
Durationofconditions12months(number of months)
Client/Family Declined
Left area before engaging
Differentialdxnotconsistentwith schizophreniform,oraffective psychosis (specify
diagnosis)
Long term incarceration
Unable toassess/engagereferred person(place detailsinnotes)
Other Reason (specify)
______
What alternative services was the client connected with if screened out?
Substance Use Treatment
Mental Health Provider (specify)
EASA program in different county
No appropriate provider available (specify)
Unable toassess/engagereferred person, no connection made
Client/Family Declined
Notes:
Portland State University EASA Referral Form 8/1/15Page 1 of 3