Recovery Insight Referral - Recovery Insight

Your Email*

Your Name*

Identifying Information

Name

Date Referred

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth

(Age >=18 Must meet age in order to continue referral)

PerformCare

Yes
No

MAID#

(10 digits)

County BSU#

Social Security Number

Gender

Male
Female

Marital Status

Single
Married
Divorced
Separated
Widowed
Partnered

Race

African American
Caucasian
Asian/Pacific Islander
Native American
Latino
Other

Race Other

Primary Language

Living Status

Lives independently
Lives with family
Lives with others
Supervised Setting
Homeless

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

OK to leave a message?

Yes
No

Reason for Referral

Education
Vocational
Social
Self Maintenance

How do you feel Peer Support Services would benefit?

Psychiatric Information

(Specify Qualifying Diagnosis: 295.XX Schizophrenia, 296.XX Major Affective Disorder 298.9X Psychotic Disorder NOS, 301.83 Borderline Personality Disorder)

Axis I

Axis II

Providers

Case Manager Name

Case Manager Phone

Case Manager Agency

Psychiatrist Name

Psychiatrist Phone

Psychiatrist Agency

Therapist Name

Therapist Phone

Therapist Agency

Medical Information

Significant Health Problems/special needs

Date of Last Medical Exam

Primary Care Physician (PCP) Name

Primary Care Physician (PCP) Phone

Primary Care Physician (PCP) Address

Street Address Address Line 2 City State ZIP Code

Does the peer have a substance use history? (Please Explain)

Current Services and/or Supports

Indicate ALL services the peer regularly utilizes

Day Program
Probation/Parole
Vocational Program
Psychosocial Rehab (ie Clubhouse, Drop-in Center)
Alcohol/Drug Treatment Services
Alcohol/Narcotics Anonymous
Educational Program
Other
No activity

The following documents are needed to complete the referral process

I have completed "Peer Support Recommendation Form-Signed by a Practitioner of the Healing Arts" (Physician-M.D. or D.O., Licensed Psychologist, Certified Registered Nurse Practitioner (CRNP), or Physician’s Assistant (P.A.)

To avoid delay, please provide all requested information.

Required Forms:

These forms may be mailed, faxed or attached below.

Download "Peer Support Recommendation Form-"Signed by a Practitioner of the Healing Arts (Physician-M.D. or D.O., Licensed Psychologist, Certified Registered Nurse Practitioner (CRNP), or Physician’s Assistant (P.A.)

Attach "Peer Support Recommendation Form

Referral Source Information

Name of Person Completing Referral Form

Phone

Email

Agency

Relationship to Individual being Referred

Is Peer aware of referral?

Yes
No

Peer Prefers

Male Certified Peer Specialist
Female Certified Peer Specialist
Doesn’t Matter

Identifying Information

Psychiatric Information

Providers

Medical Information

Current Services and/or Supports

Referral Source Information

MAKING A REFERRAL