Referrals – Brighter Future BH

BFBH - Adult Referral
BFBH - Child & Adolescent Referral
BFBH - OMHC Referral

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Initial Referral
Concurrent Referral

Client Name:

SS#: *

DOB: *

Race:

Individual and PRP

Address:

MA#: *

Phone#:

Sex: *

Marital Status:

PCP/PED:

Mental Health Diagnoses:

Primary Medical Diagnoses:

Social Elements Impacting Diagnosis

None
Educational
Financial
Access to Healthcare
Legal System/Crime
Primary Support
Housing Problems
Occupational
Other Psychosocial/Enviro
Social Environment
Homelessness
Unknown

Individual experiences at least three of the following:

Inability to maintain independent employment
Social behavior that results in interventions by mental health systems
Inability to procure financial assistance due to cognitive disorganization
Severe inability to establish or maintain social supports
Need or assistance with basic living skills

Current Medications:

Is the Individual Med Compliant?

Yes
No
Unknown

Presenting Symptoms: (Please include history of SI and HI)

Reason for Referral:

1. Self-Care Skills

Personal Hygiene
Grooming
Nutrition
Dietary Planning
Food Preparation
Self-Administration of Medication
Appearance

2. Social Skills

Community Integration Activities
Developing Natural Supports
Developing Linkages with and Supporting the Individual's Participation in Community Activities
Age-Appropriate Boundaries
Interactive Skills with Authority Figures
Anger Management
Conflict Resolution
Interactive Skills with Peers

3. Independent Living Skills

Skills necessary for Housing stability
Community Awareness
Mobility and Transportation Skills
Money Management
Accessing Available Entitlements and Resources
Supporting the Individual to Obtain and Retain Employment
Health Promotion and Training
Time Management
Individual Wellness Self-Management and Recovery

Provide a brief description of how PRP services will benefit client:

Most Recent Psychiatric Hospitalization (Where and When, If any):

Referring Mental Health Professional Signature and Credentials

Date

Referring Professional’s Name

Address and Phone Number

Psychiatrist Name

Address and Phone Number

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Date

CLIENT INFORMATION

Client’s Name

DOB *

Age

Address

City

State

Zip

Home Phone

Social Security # *

Medical Assistance # *

Email Address

Please indicate:

Sex *

Male
Female

Ethnicity

Religion

in Layout Number

Marital Status

Single
Married
Divorced

Client School

Grade

Number of Arrest in last 30 days?

Parent/Guardian:

Address:

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Returning Client:

Date

Client Name:

Date of Birth: *

SS#: *

MA#: *

Gender: *

Phone Number:

School/Grade (if applicable):

Address:

Client Availability:

Preferred Location of Services:

*SOCIAL SECURITY NUMBER MUST BE KNOWN TO PROCESS REFERRAL*

Referral Source Information

Name:

Agency (if applicable):

Phone Number:

Email Address:

Parent/Guardian Information

Name of Parent/Guardian:

Relationship:

Address:

Contact Number:

*A LEGAL DOCUMENT MUST BE PRESENTED TO SHOW GUARDIANSHIP*

Please answer the following:

Is the client of Hispanic, Latino, or Spanish origin?

Yes
No
Unavailable

Race:

White
Asian
Black/African American
American Indian/Alaskan Native
Native Hawaiian
Other Pacific Islander
Not Available

How well does the client speak English?

Well
Not so well
Not at all

Does the client speak another language other than English at home?

If Yes, what is the language?

Spanish
French
Other

Other:

Is the client deaf or do they have hearing difficulty?

Yes
No
Unknown

Is the client blind or do they have serious difficulty seeing, even when they wear glasses?

Yes
No
Unknown

REASON FOR REFERRAL: In your own words, describe the child/adult in need for therapy services. Please describe any behaviors the child/adult is exhibiting. Please specifically note any of the following whether current of a history of: Recent Hospitalizations, Suicide Attempts or Ideation, Self-harm, Violence towards others, Aggression, Domestic Violence, Psychotic Symptoms, Substance Abuse, Behavior Problems, & Mood Related Symptoms.

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Reason for Referral:

CLIENT INFORMATION

Referral Source Information

Parent/Guardian Information

Please answer the following:

Affiliated with

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Reason for Referral:

CLIENT INFORMATION

Referral Source Information

Parent/Guardian Information

Please answer the following:

Affiliated with

Quick Links

Contact

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