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Prescriber Referral Form
Adult Psychiatry Referral for Catalyst For Change
Disclaimers:
All clients must be 18 years or older.
Controlled substances will not be prescribed (stimulants, benzodiazepines, etc) or Medically Assisted Treatment.
Catalyst for Change has only one prescriber.
Service Facilitator or Referring Agency/Client Representative needs to attend all psychiatric appointments.
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CCS Client:
*
CCS
Non-CCS
Required
Client's Date of Enrollment to CCS/Outreach:
*
MM
/
DD
/
YYYY
Client Legal Name:
*
Your answer
Is the client currently experiencing homelessness or facing housing insecurity?
*
Yes
No
Other:
Preferred Name:
*
Your answer
Legal Gender:
*
Your answer
Preferred Pronouns:
*
Your answer
Age:
*
Your answer
Date of Birth:
*Note: Only treat adults
*
MM
/
DD
/
YYYY
Language Spoken:
*
Your answer
Phone Number:
*
Your answer
Email:
*
Your answer
Any Accomodations Needed:
Your answer
Legal Guardian Name (if applicable):
*
Your answer
Legal Guardian Phone Number (if applicable):
*
Your answer
Emergency Contact Name:
*
Your answer
Emergency Contact Phone Number:
*
Your answer
CCS Service Facilitator Name or Primary Point of Contact:
*
Your answer
CCS Service Facilitator/Primary Point of Contact Email and Phone Number:
*
Your answer
CCS Service Facilitation Agency:
*
Your answer
Reason for Referral:
*Note: Controlled substances will not be prescribed
*
Your answer
Mental Health Diagnoses:
*
Your answer
Current Primary Care Provider:
*
Your answer
Clinic Name:
*
Your answer
Current Psychiatric Prescriber:
*
Your answer
Clinic Name:
*
Your answer
Current Services in Place / Other Providers / Therapists:
*
Your answer
Commitment / Settlement Agreement:
*
Yes
No
If yes, date of expiration
MM
/
DD
/
YYYY
History of Substance Use Disorder:
*
Yes
No
Past Substances Used:
*
Alcohol
Marijuana
Cocaine
Crack
Heroin
Hallucinogens
Benzodiazepines
Methamphetamine
Prescription/OTC
Other:
Required
Current Substance Use Disorder:
*
Yes
No
Current Substances Used:
*
Alcohol
Marijuana
Cocaine
Crack
Heroin
Hallucinogens
Benzodiazepines
Methamphetamine
Prescription/OTC
Other:
Required
History of Overdose(s):
*
Yes
No
If yes, provide medical history/dates:
Your answer
Details of Substance Use History:
*
Your answer
Non-Psychiatric Medical Problems:
*
Your answer
Current Non-Psychiatric Medications (name, dose, frequency):
*
Your answer
Current/Past History of Suicide Attempts:
*
Yes
No
Current/Past History of Self-Harm/Non-Suicidal Self Injury (NSSI):
*
Yes
No
If yes, Self-Harm/NSSI details:
Your answer
Psychiatric Hospitalizations (Dates/Reason for Admission):
*
Your answer
Current Psychiatric Medications (name, dose, frequency):
*
Your answer
Past Psychiatric Medications and Outcomes (max dose, effectiveness, side effects, etc):
*
Your answer
Is the client interested/willing to take medications?
*
Yes
No
If not, what are the barriers?
*
Your answer
Is the client engaged in CCS/Outreach services and attending appointments regularly?
*
Yes
No
If not, what are the barriers?
*
Your answer
What insurance do you have?
*
Medicaid
Medicare
Private HMO
No insurance
Required
Is there anything else you would like us to know?
Note: Service Facilitators must attend all prescriber appointments. Contact for scheduling appointments will go through service facilitators to ensure that this is arranged at a time that works for all parties.
*
Your answer
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