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Minor
Referral Form

Psychiatric Rehabilitation services are for children, adolescents, and young adults with serious mental illness or emotional disturbance who need rehabilitation services to reduce symptoms and restore the consumer back to an appropriate functional level. Some of the services offered are social skills, self-care skills, anger management, conflict resolution skills etc. 

Referral Status:
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Does the consumer receive Social Security Disability?
REASON(S) FOR REFERRAL (Check all that apply)
PLEASE SELECT ALL SYMPTOMS AND BEHAVIORS /RISK BEHAVIORS THE CLIENT MAY BE EXPERIENCING (check all that apply):
IS THE CONSUMER CURRENTLY RECEIVING
Has the consumer had any psychiatric hospitalizations within the last 3 months?
Has the consumer been released from inpatient, a day hospital, or residential treatment within the past 3 months?
Has medication been considered to combat symptoms?

DSM-V Diagnosis

Medical Necessity Criteria

Within the Past 3 months, the individual's emotional disturbance resulted in:

Clinical Admission Criteria

Does the client need a more intensive level of care (residential treatment, inpatient psychiatric)?
Does the consumer have an active therapist?
Current frequency of treatment provided:
The youth has been engaged in active, documented outpatient treatment for:
Have less intensive levels of treatment, etc. (therapy, medication, family, or peer support) been determined to be unsafe or unsuccessful for the consumer?

Referring Clinician

Referring Clinician's Electronic Signature Attestation*

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