Pathlight Referral Form

Contact Information

Referring Agency

Program

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              Contact First Name
            
              Contact Last Name
            
              email
              
              Email
            
              phone
              
              Contact Phone #

Client Information

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              Client First Name
            
              Client Last Name
            
              Date of Birth
            
              Client ID

Does the client have a legal guardian?

Yes No

Guardian Information

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              Guardian First Name
            
              Guardian Last Name
            
              email
              
              Guardian Email
            
              phone
              
              Guardian Phone #

Guardian Street Address

Address Line 2

Provide Client Diagnoses

Reason for Placement

Has client had issues maintaining a community placement before?

Yes No

Client's Current Location

Will the client be able to visit for a placement assessment? Yes No

Is the client able to climb stairs? Yes No

Does the client use a wheelchair? Yes No

List any other assistive devices

List any mobility issues

List any medical problems or health issues

Does the client need ADL (Activities of Daily Living) assistance? Yes No

Is there a current behavioral plan in place? Yes No

Does the client require one on one or enhanced staffing?

Yes No

Does the client have any medical restrictions surrounding food, such as diet/texture/consistency/calorie count?

Yes No

Does the client have any history of (or current) substance abuse?

Yes No

Does the client have Pica?

Yes No

Does the client have any history of water intoxication?

Yes No

Does the client have a history of fire-starting or suspicious fire related behavior?

Yes No

Does the client have an Alternative Treatment Order (ATO) or Assisted Outpatient Treatment (AOT) program?

Yes No

Would you consider an out of county placement with Pathlight Community Services?

Yes No

Check any of the following the client is at risk for:

Running into the street

Refusing to come in from heat/cold

Self-mutiliation

Physically acting out towards others

Smoking inside

Suicidal ideation

This secure referral information form will be routed to key Pathlight placement personnel. You will be sent an email requesting additional documents that will be used for prompt consideration. If you have any questions, please email referrals@mipath.org *

Contact Information

Client Information

Does the client have a legal guardian?

Guardian Information

Has client had issues maintaining a community placement before?

Does the client require one on one or enhanced staffing?

Does the client have any medical restrictions surrounding food, such as diet/texture/consistency/calorie count?

Does the client have any history of (or current) substance abuse?

Does the client have Pica?

Does the client have any history of water intoxication?

Does the client have a history of fire-starting or suspicious fire related behavior?

Does the client have an Alternative Treatment Order (ATO) or Assisted Outpatient Treatment (AOT) program?

Would you consider an out of county placement with Pathlight Community Services?

Check any of the following the client is at risk for: