Date ________________________________

Referring Agency _______________________________________________________________

Address _________________________________________ Phone ________________________

Person making referral ___________________________________________________________

Client's Name ________________________________________ D.O.B. ___________________

Address ____________________________________________ Phone ____________________

Sex ______ SSN _________________________ Race _________

Source and amount of income _____________________________________________________

Presenting problems: ______________________________________________________________________________

______________________________________________________________________________

What treatment programs has this person been involved in at your facility?

______________________________________________________________________________

______________________________________________________________________________

What has the outcome been?

______________________________________________________________________________

______________________________________________________________________________

Primary Diagnosis ______________________________________ DSM IV# _______________

Current medication(s) ____________________________________________________________

Prescribing Physician ____________________________________ Phone __________________

Physician Location ______________________________________________________________

Other pertinent info: ______________________________________________________________________________

______________________________________________________________________________

Mail or fax to Intake Manager, Lowenstein House, Inc.