ACT – Assertive Community Treatment

ACT Referral Information

Name(Required)

First Last

Preferred Name/Pronouns(Required)

Date of Birth(Required)

Diagnosis(Required)

Current Medications(Required)

Reason for Referral:(Required)

Brief Description of Living Arrangements(Required)

History of or Current Substance Use(Required)

Best Way To Contact(Required)

Metrocare Medical Record Number (If Applicable)(Required)

ACT eligibility: It is important to note that ACT provides the highest level of care, therefore it is generally best practice to first attempt to address needs with through less intensive services. However, should the individual have multiple recent psychiatric hospitalizations, and a current qualifying diagnosis as indicated in the TRR, they may need ACT at this time.

1) This individual meets the eligibility criteria for ACT based on (Must Indicate):(Required)

2) This individual meets the eligibility criteria for ACT based on (Must Indicate):(Required)

3) Is the individual agreeable to receiving services from one of the clinics where Metrocare ACT is located(Required)

4) Does the individual have criminal justice history or current involvement? Please explain:(Required)

5) List the dates of the known psychiatric hospitalizations within the past two years, including the date (month/day/year) and the name of the hospital. If referring from a hospital, please attach any current treatment records.(Required)

Any additional clinical information you would like to share (if applicable):

Referring Party(Required)

First Name Last Name

Agency Affiliation(Required)

Phone(Required)

Email(Required)

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Max. file size: 23 MB.

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