|
|
|
|
|
|
|
Client Full Name:
|
|
|
Record #
|
|
|
|
|
|
|
|
|
|
|
|
|
Date of Birth:
|
|
|
|
|
|
|
Social Security Number:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Guardian/Legally Responsible
Person, Name, Address, Phone #
|
|
|
|
|
|
Referring Agency Name/Address
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Person making referral:
|
|
|
|
|
Telephone #:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Clients Current Diagnosis:
(List all, i.e., Axis I, II, III, IV)
|
|
|
|
|
|
|
|
|
|
|
|
|
Presenting Problems:
|
|
|
|
|
|
|
|
|
|
Circumstances leading to
placement:
|
|
|
|
|
|
|
Previous hospitalizations. If
yes, please list hospital
name/and dates admitted.
|
|
|
|
|
|
|
|
|
|
|
|
|
Needs:
|
|
|
|
|
|
|
Strengths:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Clients understanding of
the need for placement:
|
|
|
|
|
|
|
|
|
|
Current Living Situation (i.e. AFL, foster
care, rest/nursing, group home, detention,
jail, etc.) Please Explain in detail:
|
|
|
|
|
|
|
|
|
|
Do you currently have Medicaid, if yes please give number:
|
|
|
|
|
|
|
|
|
Appropriateness of placement:
|
|
|
|
|
|
Disposition:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Accepted:
|
|
|
Waiting List:
|
|
|
Denied:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
If denied, give reason:
|
|
|
|
|
|
|
|
|
|
Recommendation to another facility if
Agency is anable to provide services:
|
|
|
|
|
|
|
|
|
|
Comments:
|
|
|
|
|
|
|
|
|
|
|
|
