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INFO@DILIGENTHHC.COM
4334 Crawford Dr, Madison, WI 53711
612-357-6962
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Referral
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REFERALL
Referral Date:
*
Requested Service Start Date:
*
DESIRE SERVICE:
*
EMERGENCY STABILIZATION HOUSING
Typical Stay: 14 days to 3 months or permanent housing if available Staffing Ratio: 1 Staff per 1 Consumer, with awake overnight staff Is this staffing ratio suitable for this individual? YES NO (select one) Is the individual capable of navigating stairs and stepping into a tub despite home inaccessibility? This residence is an unlocked facility The individual is not actively exhibiting suicidal tendencies, homicidal behavior, or substance use (e.g., alcohol, meth, etc.)
TRANSITIONAL PLACEMENT HOUSING
Typical Stay: 14 days to 6 months or permanent housing if available Staffing Ratio: 1 Staff per 2 Consumers, with awake overnight staff Is this staffing ratio suitable for this individual? YES NO (select one) Is the individual capable of navigating stairs and stepping into a tub despite home inaccessibility? This residence is an unlocked facility The individual is not actively exhibiting suicidal tendencies, homicidal behavior, or substance use (e.g., alcohol, meth, etc.)
Personal Details
Name:
*
Social Security Number:
*
Identified Gender:
*
Medical Assistance Number:
*
Identified Race:
*
Primary Mental Illness Number:
*
Date of Birth & Age:
*
Financial County:
*
Height & Weight:
*
Billing Source:
*
Contact Information
Current Location of the Individual:
Agency:
*
Address:
*
Cell Phone:
*
Email:
*
Parent/Guardian:
Name
*
Address
*
Cell Phone:
*
Email:
*
Case Manager/Community Resource Coordinator:
(EXPECTED PRIMARY CONTACT)
Name
*
Address
*
Cell Phone:
*
Email:
*
Health and Wellness Coordinator:
Name
*
Address
*
Cell Phone:
*
Email:
*
About Me
Likes – What do I appreciate in life:
Dislikes – What do I prefer to avoid in life:
Description of a Good Day:
Description of a Bad Day:
Additional Comments:
Psychiatric/Medical Diagnoses:
Psychiatric Diagnoses:
Medical Diagnoses:
Please list and describe any chronic medical conditions:
What kind of medical assistance does this individual require?
How often does this individual seek medical services or support?
Intellectual and Developmental Disabilities (IDD) Level:
*
Borderline
Mild
Moderate
Severe
Profound
RC
None
Additional Comments:
Communication Approach
*
Verbal
Limited
ASL (American Sign Language)
Exchange Communication System)
Written
No Functional Communication Method
Additional Comments:
Self-Care/Hygiene Skills
*
Requires Full Assistance
Needs Verbal Prompts
Needs Occasional Reminders
Independent
Additional Comments:
Substance Use
Smokes/Vapes Alcohol:
*
None
Use
Abuse
Historical
Unknown Types of Substances Used:
Additional Comments:
Challenging Behaviors
Physical Aggression Towards Others
Risk Level:
*
High
Medium
Low
None
Target of Aggression:
Frequency & Duration of Incidents:
Description of Behavior:
Self-Injurious Behaviors
Risk Level:
*
High
Medium
Low
None
Frequency & Duration of Incidents:
Description of Behavior:
Calling 911/Psychiatric Emergencies
Risk Level:
*
High
Medium
Low
None
Target of Aggression:
Frequency & Duration of Incidents:
Description of Behavior:
Suicidal Behaviors
Risk Level:
*
High
Medium
Low
None
History
*
Threats
Attempts
Frequency & Duration of Incidents:
Description of Behavior:
Inaccurate Reporting
Risk Level:
*
High
Medium
Low
None
Typically Accurate Reporter:
*
Yes
No
Frequency & Duration of Incidents:
Description of Behavior:
Problematic Sexual Behavior
Risk Level:
*
High
Medium
Low
None
Frequency & Duration of Incidents:
History of Sexual Trauma:
*
Yes
No
Unknown
Targets
*
Staff
Peers
Males
Females
Other (Specify)
Sexual Offender:
*
Yes
No
Description of Behavior:
Property Aggression
Risk Level:
*
High
Medium
Low
None
Frequency & Duration of Incidents:
Description of Behavior:
Verbal Aggression
Risk Level:
*
High
Medium
Low
None
Frequency & Duration of Incidents:
Follow-through on Verbal Threats:
*
Yes
No
Target of Aggression:
Description of Behavior:
Elopement
Risk Level:
*
High
Medium
Low
None
Typical Locations:
Description of Behavior:
Engagement in Criminal Activity
Risk Level:
*
High
Medium
Low
None
History
*
Threats
Attempts
Prior/Pending Charges:
Police Involvement:
*
Yes
No
Aggression Toward Officers:
*
Yes
No
Description of Behavior:
Felony Convictions:
*
Yes
No
Probation Officer:
Name
Email
*
Phone
Use of Restrictive Measures/Emergency Manual Restraint
Utilized
*
Yes
No
Unknown
Frequency & Duration of Incidents:
***Please include any of the following documents with this completed form that you can provide to assist in accessing the individual for placement in our programs:***
*
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o Current Member Centered Plan
o Current Behavior Supports Plan Wisconsin Referral Form
o Police Reports
o Most recent Psychological
o Incident Reports
o Previous documents from Therapist
o Medical Reports
o Other: ___________________
o Other: ___________________
please note our requirements are, at least 18 years old as well as being an elder or an adult with a disability and to be eligible for Medicaid.
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