Get Act Referral Form Please Print Or Type - Adamhscc

This guide provides a comprehensive overview of how to complete the ACT Referral Form for Adamhscc efficiently and accurately. By following these instructions, users can ensure they provide all necessary information clearly and effectively.

Follow the steps to fill out the ACT Referral Form.

1. Click ‘Get Form’ button to retrieve the form and open it in your preferred editing software.
2. Begin by filling in the date at the top of the form. This should reflect the current date or the date you are submitting the referral.
3. Input the name of the referring agency and the date of admission to the agency to provide context for the referral.
4. Complete the section with the name and title of the person filling out the form, along with their telephone number for any follow-up.
5. Provide the name, title, and signature of the supervisor along with their telephone number to ensure a point of contact for verification.
6. Enter the client's name, date of birth, and relevant diagnosis. Be specific in detailing Axis I, II, III, IV, and V-GAF.
7. Answer whether the client is dually diagnosed by selecting 'Yes' or 'No' and checking applicable diagnoses.
8. Summarize the client’s psychiatric hospitalization history for the past three years, including hospital names, dates, length of stay, and reasons for admission.
9. If applicable, describe any clients who do not have repeated hospitalizations but are considered difficult to treat.
10. Include any cultural considerations pertinent to the assignment of the client to an ACT team, as well as the primary language spoken by the client.
11. Describe the consumer's current living situation and indicate the county of their residence along with the expected discharge date if applicable.
12. Specify if the client has any physical disabilities and describe them if 'Yes' is selected.
13. Indicate if there is a history of substance abuse and detail any current abuse and treatment programs involved.
14. State the client's forensic status and provide necessary details if applicable, including the legal code number.
15. Detail the rationale for the referral to an ACT team and confirm if the client is agreeable to ACT services.
16. List current medications and any additional information that may be pertinent to the referral.
17. Upon completion, save changes, download, print, or share the form as necessary. Ensure it is submitted as directed in the mailing or fax instruction.

Complete the ACT Referral Form online today to facilitate timely and effective service for your client.