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Get ACT REFERRAL FORM PLEASE PRINT OR TYPE - Adamhscc

Or: Telephone Number: Client Name: Date of Birth: Diagnosis: Axis I: Axis II: Axis III: Axis IV: Axis V-GAF Is the client dually diagnosed? If yes, check one or more: Yes No mentally ill/mentally retarded substance abuse/dependence Client s psychiatric hospitalization history during the past 3 years. (Please complete this section to the best of your ability.) Hospital Revised 2/2001 Month/Year Length of Stay Reason for Admission 2 Persons who do not have repeated hospitalizatio.

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