Value Options Referral Form For Methodist Residential Programs Page 2

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9. Were Crisis Interventions provided within the last 6 moths to client or family?
Yes 
No 
Yes 
No 
10. Was there a positive outcome?
a. Describe:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
11. Frequency of:
a. Individual therapy from a LMHP: __________Total # of sessions within the last 90
days: _________
b. Family therapy from a LMHP: ____________Total # of sessions within the last 90
days: _________
12. Other OP services received (frequency & type, i.e. case management, rehab day,
community supports):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
13. Describe the current symptoms client is displaying in the school, community, and at home
that cannot be managed safely in an outpatient setting:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
14. List type(s) and date(s) of serious physically aggressive or destructive acts committed by the
client in the last 30 days:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Yes 
No 
15. Legal involvement?
Describe (reason/type):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
16. List the dates and length of stay of acute hospitalizations in the last 12 months:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
17. What will occur in the residential setting to support client return to family/community?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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