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Referral Form- ARMHS
Referral Information
Referrals Name (required):
Client Information
Client Name (required):
DOB: (required)
PMI/ID: Put N/A if unknown (required)
Insurance Carrier: Put N/A if unknown (required)
Phone (required)
Address (required)
Are they receiving services with Touch Point Health? (required)
Yes
No
Are they currently receiving ARMHS from another Provider: (required)
Yes
No
If yes: What is the current ARMHS Providers Agency Name:
Are they currently residing in an IRTS facility, Crisis Home, or Hospital: (required)
Yes
No
If Yes: What is the current IRTS facility, Crisis Home, or Hospital Name:
Are they on a Civil Commitment: (required)
Yes
No
What areas do they need support in (Goals): (required)
Do they have a Staff preference: (required)
Male
Female
No Preference
Mental Health Information:
Do you currently have a Psychiatrist & Clinic: (required)
Yes
No
If Yes: Name Psychiatrist & Clinic:
Do you have a Therapist & Clinic: (required)
Yes
No
If Yes: Please name Therapist & Clinic
Clinical Documents:
Does the individual have a current DA within 12 months? (required)
Yes
No
Please indicate Client's availability to schedule a Diagnostic Assessment with Clinician: (required)
Send