Psychiatric Rehabilitation Adult Referral Form

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

Date of Birth:*

Gender

SSN:

Race:*

Client Phone:*

Client Email

Highest Grade Completed*

Employment Status

Name of Peer Support Provider and preferred contact:*

Name of Target Case Management Provider and preferred contact:*

Name of IOP Provider and preferred contact:*

Name of agency and preferred contact:*

Current Mental Health Information

Treating Therapist Credentials

Supervising Therapist Credentials

Solo/Group/OMHC Therapy Provider Agency Name*

Solo/Group/OMHC Therapy Phone*

Solo/Group/OMHC Therapy Provider Email

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

Max. file size: 32 MB.

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

Referral Date*

Comments

This field is for validation purposes and should be left unchanged.

Psychiatric Rehabilitation Adult Referral Form

Psychiatric Rehab Adult Referral Form

If the required field is unknown, please enter 'N/A' or 'Not Applicable'.

Client Info

Current Mental Health Information