320 North Goodman St.								MHA Office Use Only:
Rochester, NY 14607 					             	               	Date Received by: ___________
Office: 585-325-3145 x 117                                                                                                    Date Logged In by: ____________
Email: acoville@mharochester.org	                                                                                      Date Approved by: ____________					                                                                                      Date Referred Out: ____________	

REFERRAL DATE:       	
     
				                                                                 Client ID: ___________ 

	

CLIENT INFORMATION:       
Name: (First, Middle initial, Last)	D.O.B. 	Policy #/CIN: 	
Current Address: 	City: 	State: 	Zip Code:	
	Mobile Phone:                             Work phone:
Home Phone:	
Residence Type (private, group home, etc.)  	E-mail address:	
Default Communication Method: 
•	Home email
•	Home phone
•	Mail
•	Mobile phone call
•	Mobile phone text
•	Work email
•	Work phone	Gender: 
•	Female
•	Male
•	Other	
Race:                                                          Ethnicity:
•	White                                          o Hispanic                                       
•	Black/African American              o Non-Hispanic
•	Native American
•	Asian/Pacific Islander
•	Hispanic
•	Biracial
•	Other
	Additional Race: 
•	White
•	Black/African American
•	Native American
•	Asian/Pacific Islander
•	Hispanic
•	Biracial
•	Other	
Primary Language:  
•	English only
•	American Sign Language (ASL)
•	Portuguese
•	Spanish only 
•	Bi Lingual 
•	Other

                                                                     	Interpretation/Translation Needs:                      
•	Yes
•	No
•	Parent can interpret English writing
•	Parent can interpret Spanish writing
•	Other

	

CHILD INSURANCE INFORMATION (1):
Insurance ID No.: 	Date Insurance Effective:	
Insurance Provider/MCO:		

CHILD INSURANCE INFORMATION (2):
Insurance ID No.: 	Date Insurance Effective:	
Insurance Provider/MCO:		

PARENT OR GUARDIAN CONTACT:
Name:	Relationship to Client:	
Date of Birth:	Transportation:  Yes                     No	
Phone (Day):	Address:	
Phone (Evening):	City: 	Zip: 	
Does the parent/caregiver have access to transportation?  qYes     qNo         What type?  qCar     qBus   qOther_____________
Are there any special needs for transportation? If yes, please explain (i.e. wheelchair access, etc.):

CHILDS INFORMATION (1):
Primary Diagnosis (ICD-10):	
Environmental Stressors: 	

Secondary Diagnosis (ICD-10):
	
Functional impairment: 	

Medical Conditions:
	
SPMI? qYes No 	

Symptomatic Behaviors:	
Does client have any physical limitations? qYes     qNo     If yes, please describe
	
Does client take medication(s)? qYes     qNo     Please list: 

Are there any side effects we should be aware of?
	
Current involvement in treatment and programs (e.g. therapy, day-treatment, volunteering, and recreation) - please list:

CHILDS INFORMATION (2):
Primary Diagnosis (ICD-10):	
Environmental Stressors: 	

Secondary Diagnosis (ICD-10):
	
Functional impairment: 	

Medical Conditions:
	
SPMI? qYes No 	

Symptomatic Behaviors:	
Does client have any physical limitations? qYes     qNo     If yes, please describe
	
Does client take medication(s)? qYes     qNo     Please list: 

Are there any side effects we should be aware of?	

REFERRING AGENCY CONTACT INFORMATION
Referring Provider:	Title:	
Agency:	
Address:	City:	Zip: 	
Phone (Required):	Fax:	Email (Required):	
Preferred Method of Contact:
qE-mail     qMail	Relationship/role with client: 	Type of treatment:	

Health Home Care Coordinator: 	Title:	
Agency:	
Address:	City:	Zip: 	
Phone (Required):	Fax:	Email (Required):	
Preferred Method of Contact:
qE-mail     qMail	Relationship/role with client: 	Type of treatment:	
Other Provider:	Title:	
Agency:	
Address:	City:	Zip: 	
Phone (Required):	Fax:	Email (Required):	

Other Provider:	Title:	
Agency:	
Address:	City:	Zip: 	
Phone (Required):	Fax:	Email (Required):