Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Where and with whom does the consumer live? *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do they have a DBHDD Housing Voucher? *

Yes

No

Date

MM

DD

YYYY

Special/vocational training? *

Yes

No

Has the consumer ever been hospitalized for psychiatric illness? *

Yes

No

Most Recent Hospitalization

If yes, provide the following information

MM

DD

YYYY

Is the consumer currently participating in outpatient psychiatric treatment? *

Yes

No

Name of The Physician

First Name

Last Name

Phone Number

(###)

###

####

Contact Person

First Name

Last Name

Does the consumer have a history of drug or alcohol abuse? *

Yes

No

Has the consumer ever been hospitalized for drug or alcohol abuse? *

Yes

No

Date Admitted

If yes, please provide the dates of admission and discharge

MM

DD

YYYY

Date Discharged

MM

DD

YYYY

Is the consumer currently participating in outpatient substance abuse treatment?

Yes

No

Phone

(###)

###

####

Is the consumer currently participating in or receiving benefits from other community programs?

If yes, please provide the information below

Yes

No

Contact Person

First Name

Last Name

Phone

(###)

###

####

Does the consumer have a Rehabilitation Services Counselor? *

If yes, please provide the information below

Yes

No

Counselor

First Name

Last Name

Phone

(###)

###

####

Does the consumer have physical, medical problems, special diet, or allergies requiring special attention? *

Yes

No

At present, what is the consumer primary need? Please check ONE of the following services that would address this need. *

Homeless Outreach & PATH (Community Linkage, Entitlements, etc.)

Housing (Group Homes & Supervised Apts) We cannot accept applicants for Housing who have been evicted from federally-assisted housing within the last three years for drug-related criminal activity; a person who is subject to a state lifetime sex offender registration program (HUD properties only); a person who abuse or pattern of abuse of alcohol interferes with the health, safety, or right to peaceful enjoyment of the premises by other residents. We will ask applicants to comply with a criminal history check.

Supportive Services at Phoenix House, O'Hern House, Rosalynn & Presley Woods (* Individuals must be a current resident of one of these properties)

PSR Day Services (Work Adjustment, Vocational Evaluation, Day Services, Work Evaluation, Personal & Social Adjustment, Food, Transportation) *PSR-Psychosocial Rehabilitation

Supported Employment (*Task Oriented Rehabilitation Services(TORS) (Work Opportunities services including Work Exploration, Job Coaching, Job Placement, Follow Up. *TORS:For TORS, individuals must meet eligibility requirements)

Peer Support ( Recovery, Wellness, Daily Living Skills, Socialization and WHAM)

Intensive Case Management (ICM) & Community Transition Planning (CTP): Individuals with SPMI who meet following ADA criteria

Do you meet ADA criteria?

Please check those that apply

Currently served in the State hospitals

Frequently admitted to the State hospitals, 3+ hospitalizations in a 12 month period

Frequently admitted to the State hospitals, 10+ hospitalizations in lifetime

Frequently admitted to the State hospitals

Frequently seen in Emergency Rooms

Chronically homeless

Being released from jails or prisons; AND/OR In forensic status and deemed appropriate for community services by relevant court

Contact Person *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Name of Person completing the referral form *

First Name

Last Name

Date *

MM

DD

YYYY