IHOPE Referral Form Cumberland River Behavioral Health iHOPE Referral Form Step 1 of 3 33% Client InformationName: First Last Date of Birth: Race / Ethnicity: Gender:Please Select:MaleFemaleLanguage:Please Select:EnglishSpanishFrenchOtherSchool Grade: Contact Number: Message Ok?Please Select:YesNoAddress: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent or legal Guardian Information:Name of Parent or Legal Guardian: First Last Parent or Legal Guardian Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Degree of Family Involvement:Please Select:LowModerateHighContact Numbers:Contact Numbers: Payment Information:Insurance: Insurance ID: Phone:Eligibility Criteria (Check All That Apply)Aged 12-30 yearsSymptoms of Psychosis or Early Psychosis PresentResides within Cumberland River Behavioral Health areaEstimated Date of Onset of Psychosis: Referral Source Information:Complete this section so we can contact you after the referral is made. Name: First Last Phone:Email: Mailing Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Adolescent / Young Mental Health Information:Current Medication & Dosage: Current DSM 5 Diagnosis: Prescribing Physician Information:Prescribing Physician Information: First Last PhoneTreatment Relevant Medical History:Current Mental Health Symptoms:Hallucinations:Please Select:UnknownNot PresentMildModerateSevereDelusions:Please Select:UnknownNot PresentMildModerateSevereThought Disorder:Please Select:UnknownNot PresentMildModerateSevereBizarre (Psychotic) Behavior:Please Select:UnknownNot PresentMildModerateSevereAnxiety / Nervousness:Please Select:UnknownNot PresentMildModerateSevereObsessive / Compulsive:Please Select:UnknownNot PresentMildModerateSeverePhobias / Fear:Please Select:UnknownNot PresentMildModerateSevereDepressed Mood:Please Select:UnknownNot PresentMildModerateSevereMood Swings:Please Select:UnknownNot PresentMildModerateSevereSleep Disturbance:Please Select:UnknownNot PresentMildModerateSevereIrritability:Please Select:UnknownNot PresentMildModerateSevereAnger / Temper Tantrums:Please Select:UnknownNot PresentMildModerateSevereHyperactivity:Please Select:UnknownNot PresentMildModerateSevereAttention Deficit:Please Select:UnknownNot PresentMildModerateSevereParanoia:Please Select:UnknownNot PresentMildModerateSevereOppositional / Defiant To Those In Authority:Please Select:UnknownNot PresentMildModerateSevereAntisocial / Delinquent Behavior / Conduct Disorder:Please Select:UnknownNot PresentMildModerateSevereOver Sexualized Behavior:Please Select:UnknownNot PresentMildModerateSevereSomatic Complaints With No Known Medical Cause:Please Select:UnknownNot PresentMildModerateSevereOther: Other:Please Select:UnknownNot PresentMildModerateSevereSubstance Use:Please Select:UnknownNot PresentMildModerateSevereReason For Referral For Treatment:Additional Comments:Referral Completed By:Name: First Last Date Completed: CAPTCHANameThis field is for validation purposes and should be left unchanged.
