C.r.r. / S.h. /lodge/ Mprs Referral Form - Northampton County printable pdf download

NORTHAMPTON COUNTY___C.R.R. / S.H. /LODGE/ MPRS REFERRAL FORM

Please check as appropriate:

Date of Referral: _________________________________

____ Step-By-Step Full Care Adult C.R.R. (24 hr. Short term Residential)

Main St.

Referral Source:

Name:___________________________________________

____ Step-By-Step Full Care Adult C.R.R. (24 hr. Long term Residential).)

Center St.

Agency: __________________________________________

___ Salisbury House Supported Living Services (moderately staffed)

Stefko Apartments

Address:________________________________________

_________________________________________________

____ LODGE Bethlehem (Resources for Human Development)

Phone #: __________________________________________

E-mail: ___________________________________________

____ Step By Step Mobile Psych Rehab Service (non-Magellan only)

Supervisor’s Approval: ______________________________

Name: _________________________________________________

County Case#___ ___ ___ ___ ___ ___ ___ ___

(Circle if applicable)

Current Address/Last known Address:

ICM /ACT/Case Manager ______________________________

_______________________________________________________

(provider) _______________________________

_______________________________________________________

OR referred to: __________________________

Current Living Arrangement: _____________________________

Current Psychiatrist: ___________________________________

Location: __________________________ Ph#: _____________

Current Phone: _______________________________________

Diagnosis:

Date of Birth: ___________ S.S.#: _______ _______ _______

Axis I: ________________________________________________

DSM IV code: ________

Marital Status: ___________________

Gender: ______

Axis II: _______________________________________________

DSM IV code: ________

Axis III: _______________________________________________

Education (highest grade completed): ________

DSM IV code: ________

Axis IV: _______________________________________________

Emergency Contact: ____________________________________

____________________________________

Axis V: _________

____________________________________

Phone: ______________________________

Current Day Program: ____________________________________

Relationship: ______________________________

________________________________________________________

Monthly Income: _______________ Source(s): ________________

Magellan #: ____________________________ NO MA referred____

Outstanding medical conditions / physical limitations: _______

Medicare #: ____________________________ NO

___________________________________________________

Other Insurance #:__________________________________________

Representative Payee: _____________________________________

___________________________________________________

_____________________________________

Family Physician: ____________________

Phone: _______________________________

Phone: ______________________________

Legal Charges (Past and Present): __________________________________

Drug and Alcohol History:

_________________________________________________________

____________________________________________________________

_________________________________________________________

____________________________________________________________

_________________________________________________________

_______________________________________________________

_________________________________________________________

Suicidal Behavior / Attempts:

Probation / Parole Officer Name:

____________________________________________________________

_______________________________________________

__________________________________________________________

Phone: ____________________

C.r.r. / S.h. /lodge/ Mprs Referral Form - Northampton County

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