C.r.r. / S.h. /lodge/ Mprs Referral Form - Northampton County (Page 2 of 2) in pdf

History of Violence: ______________________________________________________________________________________________

Decompensation Pattern: __________________________________________________________________________________________

Fire Setting History: ______________________________________________________________________________________________

Past Agency / Hospital / Treatment Involvement:

Hospital / Agency / Treatment Facility Name & Address

Dates

____________________________________________________________________________________________________________

REASON FOR REFERRAL: These programs are designed to teach independent living skills. What does this person need help with (i.e. personal

hygiene, safety awareness, medication, housing keeping, cooking, budgeting, public transportation, scheduling appointments, structure and routine

etc.)? Be specific as possible. Some programs provide more assistance than others. What level of supervision is needed – 24 hr. 16 hr. once a day,

less? They are not intended to simply provide housing. If a consumer does not need instruction or support do not refer to these programs. For

information about applying for an independent apartment call one of the Mental Health Housing Specialists at 610-829-4831 or 610-829-4835.

________________________________________________________________________________________________________

____________________________________________________________________________________________________________

In order to expedite the referral process, please include the following (check if included):

 Most recent Psychiatric Evaluation

 Most recent Medical Examination

 Psychosocial History

 Results of Criminal Record Check



Signed Releases of Information for any previous treatment involvement / hospitalization

THE ORIGINAL REFERRAL NEEDS TO BE SENT TO THE APPROPRIATE AGENCY AND TO NORTHAMPTON COUNTY

(please check as completed):

 Step By Step

 Salisbury House

623 W. Union Blvd.

1427 Chew St

Bethlehem, PA 18018

Allentown, PA 18102

Attn: Christine Stendell

Attn: Juanita Rivera

FAX#: 610-867-9217

FAX#: 610-432-4255

 Northampton County MH/MR

Resources for Human Development – The Lodge

2801 Emrick Blvd.

425 -427 E. 4th Street

Bethlehem, PA 18020

Bethlehem, PA 18015

Attn: CRR / SLS Liaison

Attn: Ian Panyko

FAX #: 610-997-5837

FAX 610-419-3087

***When making a housing referral, please call the NC I&R Office to find out if the referred individual is

Active to the County. If not, have the case activated at that time with the I&R department. The number is

610-829-4800. Housing referrals on this referral form will not be processed without the case being activated

through I&R.

Page 2 of 2

(revised 7-23-14)

C.r.r. / S.h. /lodge/ Mprs Referral Form - Northampton County Page 2

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