Welcome to Transition House, Inc.

Client Name:

Date Of Birth: 

Referral Date:

Referral Source:

(Person & Facility):

(Phone # & Fax #):

DIAGNOSIS (include Diagnostic Impressions and Current Medical Conditions)

AXIS   I:                      

LOF:    

AXIS  II:                      

AXIS III:                      

CURRENT MEDICATIONS

 1  

4

MENTAL HEALTH HISTORY

Number of Hospitalizations:  

Age of onset:

Violent or assaultive behavior, including convictions of crimes against others:        Yes     No  

Alcohol and/or Substance Abuse:    Yes     No  

On a Scale of 1-5 (1 = low; 5 = high) Rate the Client’s:

Desire to Recover from Mental Illness:

1        2        3        4        5

Ability to Deal with a Less Structured Environment:

Likelihood of Medication Compliance:

Ability to Get Along With Others in a Community Living Environment:

Is the Client a Current Client at COCMHC?     Yes     No

If No, Date of Intake Appointment:

Does the Client have a Source of Income?     Yes     No

HAVE YOU INCLUDED THE FOLLOWING WITH THIS REFERRAL?

 Client Request for Services

(completed by client)

 Client Assessment 

(completed by client)

 TB Test results

 Consent to Release Information signed by the client that allows Transition House, Inc., access to the client’s Psychosocial History, Pertinent Medical Records, Recent Progress Notes