Referral and Screening Form
*Please complete to the best of your knowledge. If you do not know the answers, skip the question.
Referring Agency Information
Date of Referral
Name of Agency
Referral Contact Information:
Full Name
Phone Number
Email
Referring Service Request:
Outpatient Therapy
Intensive In-Home
Day Treatment
Medication Management
Residential (II or III)
Respite
Are any special accommodations needed?
Yes
No
If answer to above is (Yes), please state why below. If not then leave this section empty.
Other Agency Involvement:
Other Mental Health Agency
DSS
DJJDP
Law Enforcement
GAL
Health Dept.
Other:
If answer to above is (Other:), please state information below. If not then leave this section empty.
Client Information:
Client Name:
Client Date of Birth:
Client Gender:
Male
Female
Other
Insurance Type:
Medicaid - UNC
Medicaid - Wellcare
Medicaid - Amerihealth
Medicaid - Healthy Blue
Medicaid - Carolina Complete
Medicaid
NC Health Choice
Private Insurance
Self Pay
Does the client have a current Mental Health Provider or have they received services in the past?
Yes
No
If answer to above is (Yes), please share current or previous services received and providers (if known). If not leave this empty.
Clients Primary Care Physician:
Physician Contact Number:
Physician Practice:
Policy #:
SS #:
FSIQ:
Allergies
Current Medications:
Dosage:
Prescriber:
Guardian Information:
Guardian Name:
Guardians Contact Number:
Guardian Address:
Legal Custody:
Parents
Other Relative
DSS
Other
If answer to above is (Other), please explain. If not leave this empty.
Is Legal Guardian agreeable to receiving services?
Yes
No
If answer to above is (No), please explain. If not leave this empty.
County of Residence:
Does the client live with the guardian:
Yes
No
If answer to above is (No), please enter client’s address, contact name & number:
Is the client involved with Carolina Access?
Yes
No
School Information
Current School:
School District:
Grade:
Last Grade Completed:
Reading Grade Level:
Education Information:
IEP:
Yes
No
Behavior Intervention Plan (BIP):
Yes
No
IEP Qualifier:
504
Yes
No
Personal Education Plan (PEP):
Yes
No
Functional Behavior Assessment (FBA):
Yes
No
Can Client Read:
Yes
No
Can Client Write:
Yes
No
Reason for Referral or Current Psychiatric Symptoms
(Attach reports: suspensions, incidents, social history that reflect significant disruption, etc.)
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Other Information
Has the client ever endured a serious car accident, homelessness or a natural disaster, witnessed domestic violence, or been physically or sexually abused:
Yes
No
Is the client currently in a crisis:
Yes
No
If answer to above is (Yes), and is true crisis, forward to 1 st available O/P clinician
Does the client have a diagnosis of MR/DD:
Yes
No
If answer to above is (Yes), what are they?
Does the client have any medical conditions:
Yes
No
If answer to above is (Yes), what are they?
Any Special Preferences or Considerations (cultural, religious, etc.):
I have completed the: Focus Behavioral Health Services, LLC Referral & Screening Form Updated: 4/29/2022
Referral and Screening Form
*Please complete to the best of your knowledge. If you do not know the answers, skip the question. - Thanks!
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