Referral Form - Integrated Health Services

Referral Form/Prescreening

Name:

DOB:

Age:

Gender:

SSN:

Insurance:

Policy #:

Parent/Guardian (if under 18):

Relationship:

Name of Responsible Adult Participating in Services (if different from above):

Primary Phone:

Other(s):

Address:

City:

Zip:

Intensive In-Home Services

Mental Health Skill-Building Services

Outpatient Treatment

SHARE Programs

Other (please specify):

Psychiatrist (if applicable):

Phone:

Medications Freq/Dosage (if applicable):

History of interventions provided by the mental health, social service, judicial, school, or non-profit system:

Presenting Issue(s)/Reason for Referral/Chief Complaint: