Form 201 "Dmhas Abi Consultation Referral Form" - Connecticut

What Is Form 201?

This is a legal form that was released by the Connecticut Department of Mental Health & Addiction Services - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 10, 2017;
  • The latest edition provided by the Connecticut Department of Mental Health & Addiction Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 201 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Mental Health & Addiction Services.

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Download Form 201 "Dmhas Abi Consultation Referral Form" - Connecticut

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DMHAS ABI CONSULTATION REFERRAL
Return by Mail or Fax
To
DMHAS-ABI Community Integration Program
Beers Hall-P.O. Box 351
Middletown, CT 06457
Fax#860-262-5852
NOTE: “Asterisk” areas Required to Process Referral
Revised 3/10/17
Client Information
Form 201
*
Maiden
*
(circle)
Client Name:
Name:
M
F
*
Address:
City:
St:
Zip:
Phone:
*
Age:
DOB:
Place Of Birth:
ROI
Yes No
Race:
Religion:
*
Ethnicity:
*Primary Language:
Marital Status:
*
Veteran Status:
Education (Highest Grade)
Yes / No
DMHAS Client (circle)
Region
MPI #
*
Social Security Number
YES
NO
Employment Status:
Occupation:
Employer(Name, Location, Phone):
Income & Insurance
Type
I.D.
Amount
*
Conservator
(circle answer)
*
Person
*
Estate
*
None
*Telephone
*Name:
*Address:
Clinicians/Agency
Current Programs
CLINICIANS/AGENCY
PHONE#
Receiving Services from
DMHAS
YAS
DCF
DSS
DOC
Nursing Home
DDS
DMHAS ABI CONSULTATION REFERRAL
Return by Mail or Fax
To
DMHAS-ABI Community Integration Program
Beers Hall-P.O. Box 351
Middletown, CT 06457
Fax#860-262-5852
NOTE: “Asterisk” areas Required to Process Referral
Revised 3/10/17
Client Information
Form 201
*
Maiden
*
(circle)
Client Name:
Name:
M
F
*
Address:
City:
St:
Zip:
Phone:
*
Age:
DOB:
Place Of Birth:
ROI
Yes No
Race:
Religion:
*
Ethnicity:
*Primary Language:
Marital Status:
*
Veteran Status:
Education (Highest Grade)
Yes / No
DMHAS Client (circle)
Region
MPI #
*
Social Security Number
YES
NO
Employment Status:
Occupation:
Employer(Name, Location, Phone):
Income & Insurance
Type
I.D.
Amount
*
Conservator
(circle answer)
*
Person
*
Estate
*
None
*Telephone
*Name:
*Address:
Clinicians/Agency
Current Programs
CLINICIANS/AGENCY
PHONE#
Receiving Services from
DMHAS
YAS
DCF
DSS
DOC
Nursing Home
DDS
Name
Date
Clinical Information
*Person Making Referral:
Relationship:
Date:
*Agency:
* Phone:
Fax:
*
Reason For Referral (Please be specific)
Consultation Services
Advocacy
ABI Substance Abuse
Housing
Assistance with Discharge
Community Residence Program
ABI Verification
*Explain:
*
Has this client sustained a brain injury? (Circle answer) See definition at end of form.
Yes
No
Unknown
If yes, please describe, (date, type, loss of consciousness, injuries, etc.)
Was the client hospitalized as a result? (Circle answer)
Yes
No
Unknown
Where:
Have you requested medical records? (Circle answer)
Yes
No
When:
History of Rehabilitation Services:
Psychiatric/Substance Abuse History:
Diagnoses:
Diagnosed by:
Date of Diagnosis:
Medications:
Allergies:
DMHAS ABI CONSULTATION REFERRAL
Return by Mail or Fax
To
DMHAS-ABI Community Integration Program
Beers Hall-P.O. Box 351
Middletown, CT 06457
Fax#860-262-5852
*Client’s Location at time of Referral:
Living independently in the community
Homeless (Name of shelter if applicable: _____________________________)
Inpatient psychiatric facility (Potential Discharge Date: ________________________)
Inpatient medical facility (Potential Discharge Date: ________________________)
DOC/Corrections (Potential Release Date: ________________________)
Nursing home (Potential Discharge Date: __________________________)
Inpatient Substance Abuse (Potential Discharge Date:_________________________)
Presenting Problem:
For DMHAS ABI Office Use Only
Program Response
Date:
Receiving Staff:
Assigned Regions 1A 1B 2A 2B 3A 3B 4A 4B 5A 5B
ABI/TBI DEFINITION
Any combination of focal and diffuse central nervous system dysfunction, both immediate and/or delayed, at
the brain stem level and above. This dysfunction is acquired through the interaction of an external force such
as a blow to the head or violent movements of the body; oxygen deprivation; infection; surgery; or vascular
disorders not associated with aging. This dysfunction is not developmental or degenerative in origin.
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