ADVANCED BEHAVIORAL HEALTH, INC.
Behavioral Health Recovery Program Eastern Region Service Center
Intensive Case Management Programs
CASE MANAGEMENT REFERRAL

Referral Date: *

Please enter a valid date. Date must be between 1900 and 2999.

Client SSN #: *

Invalid SSN format (e.g., 123-45-6789).

Client Name: *

DSS/EMS ID #: *

Client Phone: *

Cell

Home

Date of Birth: *

Please enter a valid date. Date must be between 1900 and 2999.

REFERRAL INFORMATION

Referral Source: *

Phone: *

HUSKY D (LIA) Eligibility Status: *

Active

Pending Eligibility

Inactive

Potentially Eligible

Unknown

Name of Current Treatment Provider: *

Admission Date: *

Please enter a valid date. Date must be between 1900 and 2999.

Projected Discharge Date: *

Please enter a valid date. Date must be between 1900 and 2999.

Axis I Diagnosis (1): *

Axis I Diagnosis (2):

Axis III Diagnosis:

Current GAF:

Current Medication(s): *

Current Assessment of Ongoing Treatment Needs: *

Current Housing Status: *

In Stable Housing

Shelter

Homeless

Unknown

**Employment Status: ***	Currently employed part or full-time	Temporary Employment
	Unemployed	Not in labor force	Unknown

Vocational/Educational Needs: *

Briefly describe the reasons for referral for ICM services: *

If we have questions about this referral, who should we call ?

Name: *

Phone: *

* indicates it is a Required Field

*** Referral cannot be processed without an ROI. Please FAX it to ABH^® at (860) 704-6145