Date of Referral *

MM

DD

YYYY

Client's Name *

First Name

Last Name

Client's Phone Number *

(###)

###

####

Client's Date of Birth *

MM

DD

YYYY

Client's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Family/Emergency Contact Phone Number *

(###)

###

####

ACT requires one of the following diagnosis. *

Please check all applicable to the referred individual:

Major Depression

Schizophrenia

Schizoaffective Disorder

Bipolar Disorder

ACT cannot serve people who have one of the following PRIMARY diagnoses. DO NOT REFER unless the presence of the behaviors or functional limitations experienced by the person are correlated to primary mental health disorder.

Please check all applicable to the referred individual:

Borderline Personality Disorder

Anti-social Personality

Substance Use Disorder

Traumatic Brain Injury

Developmental Disability

Autism/Asperger's

Name of Person completing this form *

First Name

Last Name

Phone Number *

(###)

###

####

Reason for Referral *

(select all that apply)

Not currently receiving mental health care

Has had two or more admissions in a psychiatric/acute hospital in the past 6 months

Frequent use of emergency room/ law enforcement services in the last 6 months

Difficulty in treatment adherence (e.g. keeping appointments or medication adherence)

Unstable housing or facing imminent risk of homelessness

Has failed other traditional office-based outpatient services on their own

Has this person expressed interest in our Assertive Community Treatment program? *

Yes

No

Is the person's family/support system interested in our Assertive Community Treatment Program? *

Yes

No

Current Psychiatrist/Therapist approves of ACT referral? *

Yes

No

Not Applicable

Is the client willing to switch to the ACT Team Providers (therapist and psychiatrist)? *

(If no client cannot participate in ACT program)

Yes

No

Does the client have any physical disabilities? *

Yes

No

Does the client have a history of substance abuse: *

Yes

No

Is the client currently abusing substances? *

Yes

No

Is the client currently involved in any type of substance abuse treatment program? *

Yes

No