<p> UICMC: Community Reintegration Program: Referral Form 912 South Wood St Phone: 312-996-1065 Chicago, IL 60612 Fax: 312-413-2613</p><p>Name: _____ MRN: Address: _____ Phone: _____ Age: Date of Birth:______Insurance Provider: _____</p><p>Treating Outpatient Psychiatrist: Phone/pgr: ______</p><p>Next appointment: _____</p><p>Therapist: _____ Phone/pgr: </p><p>Next appointment: _____</p><p>Primary Out-Patient Division ( UIC Referrals Only) ______</p><p>Clinical Reason for Referral: </p><p>Substance Abuse Hx: No Yes (please explain) Hx of Self-Harm No Yes (please explain) Diagnosis: AxisI ______Dx Code: </p><p>Axis II Axis III Axis IV Axis V current Current Medications/Dosages: </p><p>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.</p>