Referral form – Phoenix, LLC

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540 685 4298
info@phoenixllc.org
Monday – Friday 8:30 – 5:00

Welcome
About Phoenix
Our services
Patients & Families

Welcome
About Phoenix
Our services
Patients & Families

Todays date

How did you hear about us?

Reason for referralMHSSOutpatientCommunity Stabilization

Clients First Name

Clients Middle Name

Clients Last Name

Clients Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Clients Marital Status

Gender Identified

Clients Date of Birth

Clients Phone Number

Clients Medicaid Number

Clients Social Security Number

Spend Down Recipient?YesNo

Dates and Amount of Spend Down

Name of person completing form *

Email Address of person completing form *

Agency name / Relationship to client

Agency phone number

Date of last physical

Clients primary care physician / specialist

Clients current or previous psychiatrist

Names, addresses and phone numbers of any specialists involved in care

Current psychotropic medications

Medical history

Reason for referral

Is the client currently receiving any services? (PACT or ICT, Crisis Stabilization, 23-hour crisis stabilization or residential crisis stabilization)

Previous Inpatient Hospitalizations or assessments to include crisis stabilization, inpatient substance abuse treatment (TDO/ECO)

Clients primary MH diagnosis

Behavioral health / substance treatment and history

Addictive behaviors (readiness to quit) to include nicotine use, gambling, video gaming, pornography.

Presenting needsDaily livingHousingIsolationLegalMedical needsMedicationParentingPhysical limitationsPsychologicalPsychiatricSubstance abuse treatment

Has client been informed that a referral was being submitted? *YesNo

If behavioral health referral, has the client consented to mental health / substance abuse services? *YesNo

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Referring party signature

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