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Client Intake/Referral Form

Referral Completed By

Referral Source

Phone

Referral Date:

Contact:

Email

Have Referrals been made to other agencies?

Patient Information

Client Name

Select an Address

Client Phone

Parent/Legal Guardian Name

Parent/Legal Guardian Address

Parent/Legal Guardian Phone

Medicaid #

Medical Record #

Birthday

Age

SSN

Parent/Legal Guardian Relationship

Ethnicity (Select all that apply):

Asian

Black/African

White

Hispanic

Native American

Pacific Islander

Prefer not to answer

Other

Reason for Referral

Diagnosis

Axis I Code

Axis II Code

Axis III Code

Axis IV Code

Axis V GAF

Axis I Description

Axis II Description

Axis III Description

Axis IV Description

Target Population

Services Requested

B3-Respite

CLS

Community Networking

Crisis REsponse

Respite

Residential Support Level

Suppored Employment

Other

Agency

QP/CM/Therapist:

Agency

Service

Contact Info

Service

Other Service(s)

QP/CM/Therapist:

Contact Info

Status of Referral:

Date Contacted

Date of Admission

Date Refused Service

Refusal Reason

Case Opened By

Service(s) Provided

Thank you for your submission!

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Tammy Russell Meadows, CEO, QP

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RUSMED CONSULTANTS, LLC does ensure that all consumers are informed of current services, wrap arround services (if applicable), and given a choice of providers with available resources.

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