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.