Mental Health Referral Form
Printable Version: Mental Health Referral Forms
Microsoft Word Format
Mental Health Referral Online Fillable Form
Date of Birth (mm/dd/yyyy)
Social Security #
Address Line 2
State / Province / Region
Zip / Postal Code
PCP Name / Number
Difficulty with basic functioning
Advanced Functioning Skills
Attending Medical Appointments
Learning New Skills
Difficulty Falling Asleep
Difficulty Staying Asleep
Difficulty Staying Awake
Maintaining Close Friendships
Understanding Social Rules of Conduct
Involved in Social/Recreational/Religious Activities
Must meet at least TWO of the following on a regular basis: (on-going)
Have difficulty establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or homelessness or isolation from social supports.
The client exhibits such inappropriate behavior that repeated interventions by the mental health, social services, or judicial system is necessary.
The client exhibits difficulty in cognitive ability to such a degree that they are unable to recognize personal danger or significantly inappropriate social behaviors.
The client requires help in basic living skills such as maintaining personal hygiene, preparing food and maintaining adequate nutrition or managing finances to such a degree that health and safety is jeopardized.
The client has an identifiable mental illness diagnosed by a psychiatrist that results in significant functional impairments in major life activities.
Clients can have a dual diagnosis (mental illness and mental retardation or mental illness and substance abuse disorder).
Professional Authorization (person completing referral form)
By checking this box you agree that all information provided above is correct. Please entering name and phone number below to confirm your agreement.