Hawthorne Veteran and Family Resource Center Recuperative Care Program Referral Form 250 N. Ash Street Escondido, CA 92027 Referring party: Date of Referral: / / Contact number: ( ) - Last admission: / / Facility/Unit: Date recuperative bed needed: / / ICD-10 Diagnosis: DEMOGRAPHIC DATA Name: Gender: Male Female Transgender Prefer not to say DOB: / / Age: Marital Status: Married Never Married Divorced Committed Relationship Other: Address: 1
H Phone: ( ) - W Phone: ( ) - Race: Ethnicity: Religious Preference: Next of Kin: Phone: ( ) - Relationship: FINANCIAL DATA Monthly Income: Source (s) of Income: VA Service Connected Disability % (if applicable): Payee/ Conservatorship/ Fiduciary: EMPLOYMENT Currently employed: Work History: Employment Goals: LIVING ARRANGEMENTS: Homeless: 2
SOCIAL SUPPORTS: MEDICAL AND TREATMENT ISSUES: ACTIVE PROBLEM(S): Ongoing medical issues and follow-up treatment: Home health needs: Special accommodations: 3
Assistive devices: Inpatient Unit Information: Unit name: Contact name: Contact number: ( ) - PRIMARY CARE PROVIDER: Name: Number: ( ) - Location: SPECIALTY CARE PROVIDER: Name: Specialty: Number: ( ) - Location: TB CLEARANCE (TB test within 1yr and/or chest x-ray within last 3 mo.): 4
Medications: Name of Medication Strength and Frequency Condition Medication Taken For Physician who Prescribed Med tes Allergies Cause Reaction Is Veteran Incontinent? 5
Is Veteran independent in ADLs: Veteran uses public transportation: Veteran self-administers medications: Strengths: Weaknesses: SUBSTANCE ABUSE AND TREATMENT HISTORY: (use, last consumption, quantity) Does Veteran have a problematic use of substances: Substance First Use Pattern of Use Date/Amount of last use Nicotine Alcohol Cannabis Cocaine Amphetamines Opioids 6
Substance Treatment history: Willing to attend treatment now? Maybe Mental Status Exam OBSERVATIONS Appearance Neat Disheveled Inappropriate Bizarre Other Speech rmal Tangential Pressured Impoverished Other Eye Contact rmal Intense Avoidant Other Motor Activity rmal Restless Tics Slowed Other Affect Full Constricted Flat Labile Other MOOD Euthymic Anxious Angry Depressed Euphoric Irritable Other COGNITION Orientation Impairment ne Place Object Person Time Memory Impairment ne Short-Term Long-Term Other Attention rmal Distracted Other PERCEPTION Hallucinations ne Auditory Visual Other Other ne Derealization Depersonalization THOUGHTS Suicidality ne Ideation Plan Intent Self-Harm Homicidality ne Aggressive Intent Plan 7
Delusions ne Grandiose Paranoid Religious Other BEHAVIOR Cooperative Guarded Hyperactive Agitated Paranoid Stereotyped Aggressive Bizarre Withdrawn Other INSIGHT Good Fair Poor JUDGMENT Good Fair Poor PSYCHIATRIC ISSUES AND TREATMENT HISTORY: Mental health diagnosis: Mental health treatment history: Therapy History: Psychiatric Hospitalization(s): Suicide History: Family History: Attempts (give detailed information i.e. date, means, plan, circumstance): History of Aggression: 8
Safety Risk Factors: Mental Health Treatment Provider: Name: Number: ( ) - LEGAL ISSUES: Current legal issues: Past legal issues: Warrants: STABILIZATION NEEDS: Referrals provided: Ensure VA Release of Information (s) have been signed and faxed to VA Liaison at 858-404- 8371 for referral to Interfaith Community Services Recuperative Care Program. 9