Patient Referral Form Terms and conditions: By submitting this referral form, you are giving permission for Acadia to research various treatment options for the person you are referring. The information is completely confidential and a resource coordinator will be in contact with you shortly after reviewing the information suggesting the best treatment options.Terms and Conditions Accepted Name of person completing this form: First Name M. Last Name Relationship to the person being referred: Address City State ZIP Telephone Email: Name of person who referred you: Agency they are associated with: Reason for referral: Legal Guardian Information: Legal guardian same as above?yesno Legal Guardian Name Address City State ZIP Cell Phone: Home Phone: Email: Does the person being referred currently reside with you?YesNo Where does the person being referred currently reside: Name of person being referred: First Name M. Last Name Gender:MaleFemaleNon-specified Date of birth: Age: Background Information: Is the person being referred currently in treatment:YesNo Please indicate treatment provider: Type of treatment services currently provided: Please describe current behaviors: Does the person being referred have a history of running away?yesnon/a Please describe: Does the person being referred have a history of suicide attempts or ideation?yesno Please describe: Does the person being referred have a history of fire setting?yesno Please describe: Does the person being referred have a history of sexually inappropriate behavior?yesno Please describe: Does the person being referred have a history of substance use?yesno Please describe the substance used, last use and frequency of use: What other treatment has been attempted in the past to address emotional, behavioral or substance use problems (therapy, hospitalizations, treatment programs, etc.) Please include approximate dates. Has the person being referred experienced any major traumatic events or changes in his or her life (ie physical, sexual or emotional abuse, rape, significant illness, grief/loss) Any current or past involvement in the legal system?yes, prior legal issuesno, prior legal issues Please describe the reasons and charges received: Probation Officer Name: Probation Officer Number: Probation Officer Email: Type of Treatment Requested:Please select... Alcohol & Drug Residential Treatment Intermediate Care Facility Mental Health Residential Treatment Therapeutic Group Home Current Psychiatric Diagnosis: Axis I: Axis II: Axis III: Axis IV: Axis V: Full Scale IQ: Educational Information: Enrolled in school?Yes, currently enrolled.No, not enrolled. School Attending: Current Grade: Highest grade completed: Individualized Educational Plan (IEP):yesno Please describe how the child does in school (include any difficulties in school): Are there any health problems, allergies or physical limitations?yesno Please describe: Healthcare Information: Insurance Company: Insurance Policy #: Group #: Policy Holder Name: Customer/Member Service Phone #: Mental/Behavioral Health Benefits Phone #: How did you hear about us?Please select... Professional Search Engine TV Commercial Radio Commercial Print Ad Online Video Ad Billboard Other: Do you have referral documentation to upload?yesno Psych Evaluations Educational Records Progress/Case Notes Medical Records Previous Treatment History Court Documentation Other Documentation Need assistance with this form?