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Agency Referral Admission
Agency Referral Form
Step
1
of
3
33%
Patient Name
*
Today's Date
*
MM slash DD slash YYYY
Referring Agency:
*
How did you hear about us?
*
Select One
MABHA Website
Social Worker
Case Manager
Medical Professional
Social Media
Marketing Materials
Family/Friend
Online
Other
If Other, please elaborate
Referring Agency Contact Person
*
Contact Phone
*
Applying For
*
CSS
RRS
IOP
OPC
Has Patient Been Admitted To This Program Before?
*
Yes
No
If Yes, When?
*
Do you have an individual that makes legal decisions for you?
*
Yes
No
If yes, provide contact information
Name
Phone #
Email
Date of Birth
*
MM slash DD slash YYYY
Social Security Number
*
Insurance Provider
*
Insurance Policy Number
*
Source of Income
*
Massachusetts Resident?
*
Yes
No
Veteran?
*
Yes
No
Housing Status?
*
Chronic Homeless
Nearly Homeless
Permanent Residence
Upon treatment completion, will the patient have safe housing available?
*
Yes
No
Last Permanent Address
*
Number of Children
*
Ages
*
Does Patient have custody?
*
Is Patient Pregnant?
*
Does Client Have Picture ID of Masshealth Card?
*
Yes
No
If yes, what?
*
Does Patient have legal action pending?
*
Yes
No
If yes, what is original charge(s) ?
*
Does Patient have outstanding warrant?
*
Yes
No
If yes, explain?
*
What is current charge?
*
Probation?
*
Convicted of Arson?
*
Yes
No
Convicted of a Sexual Offense?
*
Yes
No
Patient Substance Use History
List in order of Priority/Drug of Choice
*
Drug
Age First Use
Date of Last Use
Frequency of Use
Amount Used
Method of Use
Scheduled appointments (i.e. Court, DCF, Doctor, etc)
*
Type of Appointment
Date/Time
Location
Medical Contacts
Primary Care
*
Name
City/Town
Phone Number
Therapist
*
Name
City/Town
Phone Number
Psychiatrist
*
Name
City/Town
Phone Number
Has Patient Stopped Taking Any Medications in Past Six Months?
*
Yes
No
If Yes, What?
*
Does Patient Have Any Acute, or Chronic, Medical or Dental Needs?
*
Yes
No
If Yes, What?
*
Does Patient Have Disabilities?
*
Yes
No
If Yes, List Special Accommodations Needed?
*
Is patient on any medications?
*
Yes
No
If Yes, Include In List of Prescriptions Medications Below
*
Prescription Medication
Dose/Frequency
Refills Y/N
If No, # Days Left
Prescriber
Is patient allergic to any medications? If so, please list.
*
Yes
No
If Yes, list medication allergies
*
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OLD - On Methadone/ Suboxone/ Vivitrol?
Yes
No
Is Patient On Methadone/ Suboxone/ Vivitrol?
No
Yes, Methadone
Yes, Suboxone
Yes, Vivitrol
Where is patient's home clinic?
What dose of Methadone is patient on?
If yes, please list the medications, prescriber and home clinic contact information.
*
Prescription Medication
Dose/Frequency
Refills Y/N
If No, # Days Left
Prescriber
List of Prescriptions Medications
*
Over the Counter Meds
Dose/Frequency
Reason
History
Patient History of Mental Health Diagnosis?
*
Yes
No
If yes, explain
*
Trauma
*
Yes
No
If yes, explain
*
Eating Disorder
*
Yes
No
If yes, explain
*
Suicidal Ideation
*
Yes
No
If yes, explain
*
Suicide Attempt
*
Yes
No
If yes, explain
*
Homicidal Ideation
*
Yes
No
If yes, explain
*
Self-Injurious Behaviors
*
Yes
No
If yes, explain
*
Harm To Self Or Others
*
Yes
No
If yes, explain
*
Assault History
*
Yes
No
If yes, explain
*
To Qualify for RRS,Within The Last Three Months Has The Individual Experienced At Least One of the Following?
Inpatient Psychiatric Hospitalization
*
Yes
No
If yes, when/where?
*
At Least Two Emergency Room And/Or ESP Visits
*
Yes
No
If yes, when/where?
*
Unsuccessful Engagement In And/Or Inability to Succeed In Other Community Based Services Based On PsychoSocial or Clinical Complexity Related to Substance Use And/or Mental Health Disorders?
*
Yes
No
PLEASE NOTE: Our facility is located within close proximity of a pre-school and child day care center. Therefore, individuals who have been convicted of certain criminal offenses may be prohibited from residing at our facility and/or in violation of sentencing guidelines.
HEALTH SCREENING QUESTIONNAIRE
Client Name
*
Referring Staff Name
*
1. Do you now, or in the past 30 days, have a cough or flu like symptoms, or have you been in contact with anyone who has?
*
Yes
No
2. Do you now, or in the past 30 days, have a fever or have you been in contact with anyone who has?
*
Yes
No
3. In the past 30 days, have you travelled outside of Massachusetts, or been at an airport, or have you been at close contact with anyone who has?
*
Yes
No
4. Please complete the following
Your Temperature:
*
Date Taken:
*
MM slash DD slash YYYY
Client Signature:
*
Date:
*
MM slash DD slash YYYY
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Phone
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