Referral – AbundantLife Residence

AbundantLife Residence IRTS Intensive Residential Treatment Services Referral Form

Client Name *

Referral Date

Date Of Birth

Gender *MaleFemaleOther

Social Security Number

Client Phone Number

Insurance Name

Type

Plan Number

Monthly Income Amount

Source

Anticipated Discharge Date *

Preferred Date for IRTS Admission

Client Diagnoses

Type of Civil Commitment

Case Manager

Phone Number

Probation/Parole Officer

Phone Number

Does Client Need Permission for Home Visits?YesNo

Explanation

Person Completing This Form *

Phone Number *

Is Placement at AbundantLife Residence a Condition of the Client's Probation/Parole or Civil Commitment?YesNo

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? *YesNo

Who and/or What Services Comprise the Client's Current Support Network?

FAX your referral request to ADMISSIONS (612) 220 4454 or Email 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 IRTS at (612) 220 4454 for additional information about the program, eligibility requirements, and anticipated bed openings.

Emergency Discharge Plan

If AbundantLife Residence IRTS 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 IRTS must arrange to transfer the recipient to a provider who or setting that has the capacity to meet the recipient’s needs.

Select Emergency Discharge PlanContact Case Manager: Revocation of civil commitment and hospitalizationContact Probation/Parole Officer: Violation of probation and incarcerationTransfer to a detox facilityContact local law enforcementAlternative placement

Notify Contact 1 — Name

Notify Contact 1 — Phone Number

Notify Contact 2 — Name

Notify Contact 2 — Phone Number

Notify Contact 3 — Name

Notify Contact 3 — Phone Number

Notify Contact 4 — Name

Notify Contact 4 — Phone Number

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 prop

Client Question Sheet

Tell Us What You Are Hoping to Work On While at AbundantLife Residence?

Are There Any Fears or Concerns You Have About Treatment?

Tell Us What You Believe Has Interfered With Maintaining Stability in a Less Restrictive Environment