ADULT REFERRAL PAGE

Eb Behavioral Form (Adult)

Please fill in the details below carefully. All information will be kept confidential.

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Name *

First

Last

Date of birth *

Gender *--- Select Choice ---MaleFemaleOthers

Client Address Line 1 *

Client Address Line 2 *

City *

State *--- Please Select ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingChoice 57

Zip code

Client E-mail *

Phone Number

Client Social Seciurity Number *

Client Medicaid#

Is the client on medication? *

• Yes
• No

ICD-10 Primary Diagnosis---Please Select---F20 - SchizophreniaF21 - Schizotypal DisorderF22 - Delusional DisordersF23 - Acute and Transient Psychotic DisordersF25 - Schizoaffective DisordersF31 - Bipolar Affective DisorderF32 - Major Depressive Disorder, Single EpisodeF33 - Major Depressive Disorder, RecurrentF34 - Persistent Mood (Affective) DisordersF40 - Phobic Anxiety DisordersF41 - Other Anxiety Disorders (Generalized Anxiety Disorder)F42 - Obsessive-Compulsive Disorder (OCD)F43 - Reaction to Severe Stress and Adjustment Disorders (PTSD)F44 - Dissociative (Conversion) DisordersF45 - Somatoform DisordersF48 - Other Neurotic DisordersF50 - Eating Disorders (Anorexia Nervosa, Bulimia Nervosa)F51 - Nonorganic Sleep DisordersF52 - Sexual Dysfunction not caused by organic disorderF60 - Specific Personality Disorders (Borderline, Antisocial, etc.)F63 - Habit and Impulse DisordersF68 - Other Disorders of Adult Personality and BehaviorF70 - Mild Intellectual DisabilitiesF71 - Moderate Intellectual DisabilitiesF72 - Severe Intellectual DisabilitiesF73 - Profound Intellectual DisabilitiesF79 - Unspecified Intellectual DisabilityF80 - Specific Developmental Disorders of Speech and LanguageF81 - Specific Developmental Disorders of Scholastic SkillsF82 - Specific Developmental Disorder of Motor FunctionF84 - Pervasive Developmental Disorders (Autism Spectrum Disorder)F90 - Attention Deficit Disorder (ADHD)F91 - Conduct DisordersF93 - Emotional Disorders with Onset Specific to ChildhoodF94 - Disorders of Social Functioning with Onset Specific to ChildhoodF95 - Tic Disorders (including Tourette’s Syndrome)F99 - Unspecified Mental Disorder

Is the client currently receiving mental health treatment or being transferred?

• Yes
• No

Duration of Current Episode of Treatment

• Yes
• No

Current Frequency of Treatment

• Yes
• No

Is the participant currently receiving services from one of the following?

• Yes
• No

Does the client have marked inability to procure financial assistance?

• Yes
• No

Provider Agency/Organization Name

Provider Name and Credentials

Phone Number

Email *

Clinical Supervisor (If applicable)

Signature

DATE

Submit