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Client Referral
Consumer Grievance Form
Referral
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Client Referral
Psychiatric Rehabilitation Adult Referral Form
Psychiatric Rehabilitation Adult Referral Form
Psychiatric Rehab Adult Referral Form
"
*
" indicates required fields
If the required field is unknown, please enter 'N/A' or 'Not Applicable'.
Name of person completing referral
*
Email of person completing referral
*
Client Info
Client Name
*
First
Middle
Last
Date of Birth:
*
MM slash DD slash YYYY
Gender
Select Gender
Male
Female
SSN:
Race:
*
Select Race
Black or African American
American Indian
Asian
Other Race
White
Insurance
*
At a minimum, please enter your primary insurance. If you have secondary insurance, please click the plus sign to the right of the fields to add your secondary insurance information.
Insurance Coverage Type (Medicaid, Medicare, Private Insurance, Uninsured)
Policy #
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Address
*
Street Address & Apartment/Suite #
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Maine
Maryland
Massachusetts
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Mississippi
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Montana
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New York
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North Dakota
Northern Mariana Islands
Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Client Phone:
*
Client Email
Highest Grade Completed
*
Pre-School
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College
Vocational
Does the client give permission to be contacted via social media?
*
Yes
No
Social Media Contact Information
Social Media Platform
Username
Add
Remove
Employment Status
Employed Fulltime
Employed parttime
Unemployed
Military Experience
*
Yes
No
Currently Pregnant:
*
Yes
No
Under Legal Guardianship
*
Yes
No
Reason for Referral:
*
Check all that apply.
Abuse (Physical/Emotional/Sexual)
Academic/Educational Challenges
Behavior/Conduct Challenges
Emotional/Mental Illness
Legal (Custody or Incarceration)
Psychiatric/Med Mgmt
Physical Health Challenges
Relational Conflict
Social/Interpersonal Challenges
Substance Abuse
Housing Instability
Symptoms and Behaviors/Risk Behaviors:
*
Check all that apply.
Anxiety/Panic
Abandonment/Attachment Problems
Depressed/Low Energy
Fire Settings/Pyromania
Homicidal/Suicidal Ideations
Hyperactive/Impulsive
Isolative/Loner
Lying/Manipulative
Manic/Obsessive/Compulsive Mood
Oppositional Defiant/Verbal Aggression
Physical Aggression/Property Destruction
Running Away/AWOL
Self-Care Deficit
Self-Injurious Behavior
Stealing/Theft
Trauma (Severe)
Truancy
Services Requested
*
Check all that apply.
Alcohol/Drug use
Behavior Norms
Community Resource Access
Communication Skills
Coping Skills
Emotional Health Practices
Family Relationships
Financial Mgmt/Benefits Access
Healthy Social Networks
Housing Stablity/Maintenance
Leisure/Social Activities
Nutrition/Fitness
Personal Hygiene
Personal Safety
Problem-Solving
Productivity (Home/School/Work)
Sexuality
Time Management
Is the client currently receiving outpatient mental health therapy?
*
Yes
No
Is the individual currently receiving Peer Support Services?
*
Yes
No
Name of Peer Support Provider and preferred contact:
*
Is the individual currently receiving Target Case Management Services?
*
Yes
No
Name of Target Case Management Provider and preferred contact:
*
Is the individual currently receiving Alcohol/Substance Intensive Outpatient (IOP) services?
*
Yes
No
Name of IOP Provider and preferred contact:
*
Preferred Available Day(s) for Initial Appointment
*
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Time of Initial Appointment
*
Morning
Afternoon
Evening
Are you affiliated with an agency
*
Yes
No
Name of agency and preferred contact:
*
Current Mental Health Information
Current Mental Health Diagnosis & Medication
*
ICD Code & Description
Date Diagnosed
Prescribed Medication to Treat
Diagnosed By:
Add
Remove
Treating Therapist Name:
*
First
Last
Treating Therapist Credentials
Select Credentials
LCSW-C
LCSW
LMSW
LCPC
LGPC
CNRP-PMH
LCADC
Supervising Therapist Name
First
Last
Supervising Therapist Credentials
Select Credentials
LCSW-C
LCSW
LMSW
LCPC
LGPC
CNRP-PMH
LCADC
Solo/Group/OMHC Therapy Provider Agency Name
*
Solo/Group/OMHC Therapy Provider Agency Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Solo/Group/OMHC Therapy Phone
*
Solo/Group/OMHC Therapy Provider Email
Is there recent documentation (Psycho-Social Assessment or Psychiatric Evaluation) to verify the diagnosis?
*
Yes
No
Please upload evidence of the Clinical Diagnosis that supports this request for Adult CSS/Psych Rehab Services
*
Upload Clinical Diagnosis Evidence Here
Drop files here or
Select files
Max. file size: 32 MB.
Untitled
Does the Treating and Supervising Therapist support this referral to WIN CSS/Psych Rehab Services?
*
Yes
No
As the Supervising or Treating Therapist, I authorize WIN Team CSS (Psych Rehab Services) to receive, collect and verify the information provided on this form for screening purposes, to confirm the eligibility and appropriateness of services available, and initiate WIN community behavioral health services to the above-referenced adult.
*
Credentials
Select Credentials
LCSW-C
LCSW
LMSW
LCPC
LGPC
CNRP-PMH
LCADC
Referral Date
*
MM slash DD slash YYYY
If you have a signed release of information, please upload it. There is a link to WIN's release on referral info page
Max. file size: 32 MB.
Comments
This field is for validation purposes and should be left unchanged.
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