Referral form

Referral for Lookout Mountain Community Services IDD Program
Individuals Information
Name *

Name Client ID # (if applicable)
Address *

Address

Indirizzo Riga 2

City

Post Code
Phone Number *
Social Security Number *
Date of Birth *

Month Day Year
Date
Living Situation

Alone With Parent(s) Spouse Children Friends
Primary Insurance Information
Insurance Information

Medicaid Medicare Amerigroup CareSource PeachState WellCare Private Insurance
Insured Identification Number
Insurance Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Does the individual have a secondary insurance?

Yes No
Secondary Insurance Information

Skip section if not applicable
Insurance Information

Medicaid Medicare Amerigroup CareSource PeachState WellCare Private Insurance
Insured Identification Number
Insurance Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Diagnosis Information
Primary Diagnosis *
Secondary Diagnosis
Other Medical Diagnoses
Referring Agency Information
Agency Name *
Referral Staff Name *

First Name Last Name
Referring Agency Admission Date (date individual came to your agency)

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact Number
E-mail
Medical/Psychiatric Information
Medications *
(Name, Dose, Frequency)
History of Medication Compliance

Excellent Good Fair Poor
How does individual behave when off medications?
Currently uses alcohol/drugs?

Yes No
If Yes, please explain
Compliance with treatment plan

Excellent Good Fair Poor
Comments
Psychiatric Hospitalizations
(Hospital Name, Date, Length of Stay)
Psychosocial Treatment Needs
Behavioral Concerns/Comments *
List all services provided to this individual during the past twelve months
Interpretive Summary (last 90 days)
Living Skills

Rate living skills in the following areas

Doesn't Need Assistance

Needs Some Assistance

Needs Ongoing Assistance

Housekeeping

Food Prep/Storage

Grocery Shopping

Transportation

Communication
(use phone, make appointments)

Leisure time planning

Money Management

Ability to Arrange Healthcare

Interpersonal Skills

Other Information
Please click 'Browse' to select and upload any supporting documentation
Should be Empty:

Referral for Lookout Mountain Community Services IDD Program

Individuals Information

Primary Insurance Information

Secondary Insurance Information

Diagnosis Information

Referring Agency Information

Medical/Psychiatric Information

Living Skills