UICMC: Community Reintegration Program: Referral Form
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UICMC: Community Reintegration Program: Referral Form 912 South Wood St Phone: 312-996-1065 Chicago, IL 60612 Fax: 312-413-2613
Name: _____ MRN: Address: _____ Phone: _____ Age: Date of Birth:______Insurance Provider: _____
Treating Outpatient Psychiatrist: Phone/pgr: ______
Next appointment: _____
Therapist: _____ Phone/pgr:
Next appointment: _____
Primary Out-Patient Division ( UIC Referrals Only) ______
Clinical Reason for Referral:
Substance Abuse Hx: No Yes (please explain) Hx of Self-Harm No Yes (please explain) Diagnosis: AxisI ______Dx Code:
Axis II Axis III Axis IV Axis V current Current Medications/Dosages:
Referring Individual’s Signature______Date______Please call Community Reintegration 312-996-1065 or Veronica Stefanek 31-413-1186 to schedule an intake appointment for your client.