Allover Healthcare Group - Referrals Form - Allover Healthcare Group LLC

Consumer Name:*

Age:*

D.O.B:*

Gender:*

Marital Status:*

Address:*

City:*

State:*

Zip Code:*

Social Security #:*

Daytime Phone:*

Cell Phone:

Home Phone:

Primary Language:

Need interpreter:

Race:*

Ethnicity:*

Transition:*

Education Level:*

In School?

Yes No

School Name:

Medicaid/Insurance:*

Insurance Name: *

Insurance #*

Medicaid #: *

Authorized:*

Yes No

Employment Status:*

# of Arrests in past 30 days:*

Veteran?

Yes No

Homeless?

Yes No

Does the applicant Adult/Minor have guardian?

No Yes, guardian of person Only Yes, guardian of property only Yes, person and property

If the applicant have guardian, please provide guardian information:

Guardian Name:*

Guardian Phone:*

Address:*

City:*

State:*

Zip Code:*

Diagnosis: please indicate current DSM diagnoses in the Behavioral Health Diagnosis input box. (MUST HAVE AXIS I DIAGNOSIS) ADULTS MUST HAVE ONE OF THE FOLLOWING DIAGOSIS FOR PRP ELIGIBILITY

F20.9 Schizophrenia
F20.81 Schizophreniform Disorder
F25.0 Schizoaffective Disorder, Bipolar Type
F25.1 Schizoaffective Disorder, Depressive Type
F28 Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

F29 Unspecified Schizophrenia Spectrum and Other Psychotic Disorder
297.1/F22 Delusional Disorder
F33.2 Major Depressive Disorder, Recurrent Episode, Severe
F33.3 Major Depressive Disorder, Recurrent Episode, W/ Psychotic Features
F21 Schizotypal Personality Disorder

F31.13 Bipolar I Disorder, Current or Most Recent Episode Manic, Severe
F31.2 Bipolar I Disorder, Current or Most Recent Episode Manic Psychotic Features
296.53 Bipolar I Disorder, Current or Most Recent Episode Depressed, Severe
F31.13 Bipolar I Disorder, Most Recent Manic, Severe
F31.4 Bipolar I Disorder, Current or Most Recent Depressed, Severe

F31.0 Bipolar I Disorder, Current or Most Recent Episode Hypomanic, Unspecified
F31.9 Bipolar I Disorder, Current or Most Recent Episode Unspecified
F31.9 Unspecified Bipolar and Related Disorder
F31.81 Bipolar II Disorder
F60.3 Borderline Personality Disorder

Medical Diagnosis:*

Behavioral Diagnosis - PLEASE USE Axis I: ICD CODE for PRP:*

Diagnosis Given By:*

Current Medication:*

History of Challenges and Rehabilitation Needs:*

Please check all that apply to the consumer:

Suicide Risk Danger to Self or Others Urgent/Critical Medical Condition Immediate Threat(s)
Past Psychiatric Admission(s) Previous Outpatient Treatment If yes, do you have a copy of the aftercare plan?
Is there a current or previous substance use? If yes, currently in treatment?

Referral Name:*

Referral Facility/Agency:*

Referral Phone:*

Referral Email:*

Client Therapist Name (If Any):

Therapist Phone:

Client Psychiatrist Name (If Any) :

Psychiatrist Phone:

Describe Referral Reason (PLEASE BE SPECIFIC):*

Attach any supporting document:

Browse

Referral Signature:*

Referral Credentials:*

Referral Date:*