Referral: Group Therapy Form

Report 2 Downloads 77 Views
WWW.HEALTHYMINDSLV.COM

Clinical Group Therapy Referral This is a supplement to the Healthy Minds referral form Name: _______________________________ DOB: _________________ Date: ___________________ ☐ Dialectic Behavioral Therapy - Treats adolescents’ ages 13-17 years old. The DBT group is a 12week group session. Selection criteria: ☐ Yes ☐ No Currently enrolled in FFS Medicaid ☐ Yes ☐ No Client is between the ages of 13 – 17; Date of birth: ___/___/______ ☐ Yes ☐ No Client has a Mental Health diagnosis such as; Mood & Depressive Disorder, Anxiety Disorder, Post -Traumatic Stress Disorder, Substance Use Disorder, but not limited to. ☐ Yes ☐ No Client has displayed at least ONE of the following: self-harming behaviors, moderate to severe suicidal ideation or attempts, mood dysregulation, impulsivity that involves risky behaviors such as substance use, sexual promiscuity, chronic runaways, or putting self in harm's way.   ☐ Trauma Focused Cognitive Behavioral Treatment - The groups are structured per the following age groups: ☐ 8-12 years old; ☐ 13-17 years old. The TF-CBT group is an 8-week group session. Selection criteria: ☐ Yes ☐ No Currently enrolled in FFS Medicaid ☐ Yes ☐ No Client is between the ages of 8 – 17; Date of birth: ___/___/______ ☐ Yes ☐ No Client has a diagnosis of Adjustment Disorder, Mood & Depressive Disorder, Anxiety Disorder, Post -Traumatic Stress Disorder. ☐ Yes ☐ No Client has witnessed or been victim of significant trauma.

☐ Yes ☐ No ☐ N/A Caregiver & Client have been notified of group referral. Caregiver/Client have been given the date, location and time of group. Additional Notes: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

RETURN TO [email protected] (702) 455-4629 Rev. 3/13/17

Recommend Documents