Referral Home Referral If you know someone needing Intensive Residential Treatment Services, our referral process makes it simple. CLIENT NAME(Required)REFERRAL DATE(Required) MM slash DD slash YYYY DATE OF BIRTH(Required) MM slash DD slash YYYY GENDER(Required) Male Female SOCIAL SECURITY NUMBERCLIENT PHONE NUMBERINSURANCE NAMETYPEPLAN NUMBERMONTHLY INCOME AMOUNTSOURCEANTICIPATED DISCHARGE DATE MM slash DD slash YYYY PREFERRED DATE FOR IRTS ADMISSION MM slash DD slash YYYY CLIENT DIAGNOSESCASE MANAGERPHONE NUMBERPROBATION/PAROLE OFFICERPHONE NUMBERDoes client need permission for home visits? Yes No PLEASE CHECK ALL THAT APPLY Medication Noncompliance History of Violence to Property or Fire Setting Suicidal Behaviors Chemical Dependency or Use Mobility Concerns History of Violence Towards a Person History of Sexual Abuse Self-Injurious Behaviors Legal Issues Physical Health Concerns Select AllEXPLANATIONPERSON COMPLETING THIS FORMPHONE NUMBERIS PLACEMENT AT AbundantLife Residence A CONDITION OF THE CLIENT’S PROBATION/PAROLE OR CIVIL COMMITMENT? Yes No WHAT IS THE DISCHARGE PLAN FOLLOWING IRTS TREATMENT?WHAT REFERRALS ARE IN PLACE FOR THIS PERSON FOLLOWING THEIR IRTS PLACEMENT?IS THIS CLIENT IN DRUG COURT OR MENTAL HEALTH COURT? Yes No WHO AND/OR WHAT SERVICES COMPRISE THE CLIENT’S CURRENT SUPPORT NETWORK? Email your referral request to abundantliferesidence@gmail.com. Include other appropriate documentation as available: Functional Assessment LOCUS Assessment Medication List Hospital or crisis center records Copy of physical exam within the past 30 days Record of TB screening in past 3 months Other treatment records that support the need for IRTS placement When all information is received for the referral, a decision will be made within 72 hours. Please call AbundantLife Residence at 612-220-4454 for additional information about the program, eligibility requirements, and anticipated bed openings. EMERGENCY DISCHARGE PLAN If AbundantLife Residence cannot meet the recipient’s health and safety needs, or it is determined that a particular recipient presents an imminent danger to themselves or others, AbundantLife Residence must arrange to transfer the recipient to a provider who or setting that has the capacity to meet the recipient’s needs. THE PLAN Contact Case Manager: Revocation of civil commitment and hospitalization Contact Probation/Parole Officer: Violation of probation and incarceration Transfer to a detox facility Contact local law enforcement Alternative placement LIST ANYONE WHO MUST BE NOTIFIED:NAMEPHONE NUMBER Add Remove The following actions are considered to be health and/or safety hazards that will result in an Emergency discharge. The Treatment Team, including the recipient’s case manager and/or probation officer, will be consulted in the below instances: Assault of another recipient or staff person Any action that puts themselves or others in serious danger Alcohol, drugs, or paraphernalia brought into the house or onto the property Alcohol or drug use in the house or on the property CLIENT QUESTION SHEETTell us what you are hoping to work on while at AbundantLife Residence?Please check which areas are concerns for you that we can help you with while in our program: Education on mental health Managing mental health symptoms Child visitation/social service involvement Physical health issues Basic living skills Anger management Rebuild family relationships Maintaining sobriety Social skills Legal concerns Employment Housing Are there any fears or concerns you have about treatment?Tell us what you believe has interfered with maintaining stability in a less restrictive environmentd By submitting this form you agree to the terms of the Privacy Policy.CAPTCHA
