Social Elements Impacting Diagnosis (Check all that apply): None Access to Health Care Housing Problems Social Environment Educational Legal System/Crime Occupational Homelessness Financial Primary Support Other Psychosocial/Enviro. Unknown Individual experiences at least 3 of the following: Inability to maintain independent employment Severe inability to establish or maintain social supports Social behavior that results in interventions by the mental health system Need or assistance with basic living skills Inability, due to cognitive disorganization, to procure financial assistance to support living in the community If the individual has a co-occurring Substance Use Disorder (cannot be primary diagnosis) ICD-9 ICD-10 DSM 5 Diagnosis ICD-9 ICD-10 DSM 5 Diagnosis 305.00 F10.10 Alcohol Use Disorder – Mild 304.20 F14.20 Stimulant-Related Disorder – Cocaine – Severe 303.90 F10.20 Alcohol Use Disorder – Moderate 305.70 F15.10 Stimulant-Related Disorder – Amphetamine-type substance – Mild 303.90 F10.20 Alcohol Use Disorder – Severe 304.40 F15.20 Stimulant-Related Disorder – Amphetamine-type substance – Moderate 305.20 F12.10 Cannabis Use Disorder – Mild 304.40 F15.20 Stimulant-Related Disorder – Amphetamine-type substance – Severe 304.30 F12.20 Cannabis Use Disorder – Moderate 305.1 Z72.0 Tobacco Use Disorder – Mild 304.60 F12.20 Cannabis Use Disorder – Severe 305.1 F17.200 Tobacco Use Disorder – Moderate 305.50 F11.10 Opioid Use Disorder – Mild 305.1 F17.200 Tobacco Use Disorder – Severe 304.00 F11.20 Opioid Use Disorder – Moderate 305.90 F19.10 Other (or Unknown) Substance Use Disorder – Mild 304.00 F11.20 Opioid Use Disorder – Severe 304.90 F19.20 Other (or Unknown) Substance Use Disorder – Moderate 305.60 F14.10 Stimulant-Related Disorder – Cocaine – Mild 304.90 F10.20 (or Unknown) Substance Use Disorder – Severe 304.20 F14.20 Stimulant-Related Disorder – Cocaine – Moderate 304.20 F14.20 Stimulant-Related Disorder – Cocaine – Severe Include any secondary Behavioral Health Diagnoses (If any): Medical Diagnoses (If any):
Reason for Referral: Self-care skills: Personal hygiene, Grooming Nutrition Dietary planning Food preparation Self administration of medication Other: Social Skills: Community integration activities Developing natural supports Developing linkages with and supporting the individual’s participation in community activities. Other: Independent Living Skills: Skills necessary for housing stability Community awareness Mobility and transportation skills management Accessing available entitlements and resources Supporting the individual to obtain and retain employment Health promotion and training Individual wellness self management and recovery. Other: Other: Any additional information that you feel be helpful in serving this individual: Who is making this referral: Self Family Case Manager Other Contact Information of the person making referral (if not self): Name: Phone: Psychiatrist: Address: Phone: Therapist: Address: Phone: Primary Care: Address: Phone: Check all that apply: I am referring this person for Psychiatric Rehabilitation Day Services (day program) I am referring this person for Supported Living Services (in-home supports & case management) __________________________________________________ Referring Clinician’s Name & Credentials (Print) __________________________________________________ _________________ Referring Clinician’s Signature Date