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IRS Form 990
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Home
About
Programs & Services
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Annual Report
IRS Form 990
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ACT Provider Referral Form
Thank you for your referral to our Assertive Community Treatment program. Please fill out the following form and submit it for review.
This form can also be downloaded and submitted by email to Lizzie, our ACT Team Coordinator.
Lizette Fitts -
lfitts@questreno.com
Download Form
Date of Referral
*
MM
DD
YYYY
Client Information
Client's Name
*
First Name
Last Name
Client's Phone Number
*
(###)
###
####
Client's Email
Client's Date of Birth
*
MM
DD
YYYY
Client's Age (must be 18+)
Client's Marital Status
Never Married
Married
Separated
Divorced
Widowed
Client's Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Current Location (if other than home)
Lives with:
Client's Primary Language
Client's Insurance
*
Emergency Contact Information
Primary Family/Emergency Contact
*
Relationship to Client
Primary Family/Emergency Contact Phone Number
*
(###)
###
####
Client Diagnosis
ACT requires one of the following diagnosis.
*
Please check all applicable to the referred individual:
Major Depression
Schizophrenia
Schizoaffective Disorder
Bipolar Disorder
ACT cannot serve people who have one of the following PRIMARY diagnoses. DO NOT REFER unless the presence of the behaviors or functional limitations experienced by the person are correlated to primary mental health disorder.
Please check all applicable to the referred individual:
Borderline Personality Disorder
Anti-social Personality
Substance Use Disorder
Traumatic Brain Injury
Developmental Disability
Autism/Asperger's
Referral Information
Name of Person completing this form
*
First Name
Last Name
Referring Agency
Relationship to Client
Phone Number
*
(###)
###
####
Reason for Referral
*
(select all that apply)
Not currently receiving mental health care
Has had two or more admissions in a psychiatric/acute hospital in the past 6 months
Frequent use of emergency room/ law enforcement services in the last 6 months
Difficulty in treatment adherence (e.g. keeping appointments or medication adherence)
Unstable housing or facing imminent risk of homelessness
Has failed other traditional office-based outpatient services on their own
Has this person expressed interest in our Assertive Community Treatment program?
*
Yes
No
If no, why?
Is the person's family/support system interested in our Assertive Community Treatment Program?
*
Yes
No
If no, why?
Current Providers
Primary Care Doctor:
*
Answer "N/A" if client does not have a primary care doctor currently
Psychiatrist:
*
Answer "N/A" if client does not have a psychiatrist currently
Therapist:
*
Answer "N/A" if client does not have a therapist currently
Current Psychiatrist/Therapist approves of ACT referral?
*
Yes
No
Not Applicable
If no, why?
Is the client willing to switch to the ACT Team Providers (therapist and psychiatrist)?
*
(If no client cannot participate in ACT program)
Yes
No
Additional Client Information
Does the client have any physical disabilities?
*
Yes
No
If yes, please describe:
Does the client have a history of substance abuse:
*
Yes
No
If yes, describe the types of substance abused:
Is the client currently abusing substances?
*
Yes
No
Is the client currently involved in any type of substance abuse treatment program?
*
Yes
No
Thank you for your referral! We will contact you with any further questions.