Southwest
Counseling Center, Inc.
ACT Team
Referral
Name:________________________________Maiden
Name:_________________________________
SS#:__________________________DOB:________________________Phone:__________________
Address:___________________________________________________________________________
Medicaid #:_________________Medicare #:_____________Income Source_____________________
Allergies:___________________Physical
Health Issues:_____________________________________
Primary
Language Consumer:
________________________
Consumer family: ________________________
Must have a primary diagnosis of
Schizophrenia, Schizoaffective disorder or Bipolar with psychotic features.
Individuals
with a primary diagnosis of substance abuse,
brain injury or Axis II disorders are not appropriate for ACT.
Diagnosis-include substance abuse/dependency Current Medications:
Axis I:________________________________ 1.___________________________
______________________________________ 2.___________________________
Axis II:________________________________ 3.___________________________
Axis III:_______________________________ 4.___________________________
Axis IV:_______________________________ 5.___________________________
Axis V:_______________________________ 6.___________________________
Admission Criteria
Four psychiatric hospitalizations in the past 24 months or lengths of stay totaling over 30 days in the past 12 months.
(please list hospital, admit and discharge dates and reason)__________________________________________
__________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Priority is given to those with the
following:
___Persistent
or recurrent severe affective, psychotic or suicidal symptoms
___Homeless,
imminent risk of losing housing OR living in substandard/unsafe housing OR
residing in supported housing
but clinically assessed to be able to
live in a more independent living situation if intensive services are provided.
___High
risk of or criminal justice involvement in the past 12 months (please list
arrest/release date and place)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________Probation?
____________________Parole?____________________
___Inability
to consistently perform the range of practical daily living tasks required for
basic adult functioning
___Inability
to participate in traditional office-based services
___Co-existing
substance abuse disorder greater than 6 months – Drug (s) of
choice______________________________
Symptoms
& Behavioral Challenges (risk of harm to self or others,
etc)________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Current
Living Situation:_____________________________________________________________________________
Other
issues affecting treatment(Substance use w/drug of choice, employment and
family involvement)
_________________________________________________________________________________________________
Referred
By:_______________________________________________________________________________________
Phone:_____________________________E-mail:__________________________________Date:___________________
* Please include a release of information for
the provider/facility submitting this referral.
* Please include a copy of the latest
psychiatric evaluation, other pertinent information that may be helpful and
releases of
information
for all prior hospitalizations.
Referrals which do not
include releases and are not fully completed may take longer to process.
*
Please phone the ACT office if
you have questions regarding the referral process: Office
# (575) 527-7975 Fax: (575) 647-2898