249 NC-54 #320
Durham, NC 27713

919-907-3334 Main

919-907-3335 Fax

919-225-0636 Crisis Line

Mon - Fri: 8:00AM - 6:00PM

Sat - Sun: Closed

Questions?

info@bdihs.com

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Adult Referral Form

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ADULT REFERRAL FORM

Name of Referral Source

Company/Affiliation

Work Phone

Email

Client Information

Name of Referral Source

Phone

Best Time to Call

Client Address

Social Security Number

Date of Birth

Sex

Insurance

Medicaid Number

Depression

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Mania

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Anxiety

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Somatization/Conversion

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Psychosis

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Thinking/Cognition/Memory

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Impulsive/Reckless/Aggressive

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Activities of Daily Living

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Eating Disorder

First

Second

Third

Comments (type N/A if not applicable)

Medical/Physical Conditions

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Substance Abuse/Dependence

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Job/School Performance

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Family Problems

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Marital Problems

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Social Problems

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Legal Problems

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Housing Problems

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Financial Problems

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Other

Mild

Moderate

Severe

Comments (type N/A if not applicable)

Check if called BDIHS 919-907-3334 to complete screening and referral process.

Appointment Date Assigned by Screener

Time