ODYSSEY HOUSE REFERRAL FORM
1125 North Tonti Street, New Orleans, Louisiana 70119
MUST ARRIVE WITH 30 DAY SUPPLY OF all MEDICATIONS
Referrals will not be admitted without: ANTIPSYCHOTICS/COAGULANTS/SEIZURE MEDICATION
Date: ___________________
Referral Source/Name/Phone Number: ____________________________________________________________________
_____________________________________________________________________________________________________
Current Pay source: (Please Circle)
Medicaid Medicare Private Insurance _______________________ Self-Pay
Has a MEDICAID Application been completed? Yes __ No __ If so, date/where __________________________________
CLIENT DEMOGRAPHICS:
Name: ____________________________________ SS#: _______________ DOB: ___/___/______ Race: _______
Marital Status: S M W D Address: __________________________________________________________________
Contact Number: ______________________________
REQUESTED SERVICE (circle one):
Detox
CURRENT MONTHLY INCOME:________________________
Short Term Residential
LTH/IOP (long term)
Reason client seeking services now/motivation for treatment:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Past OHL stay: Yes __ No __ If yes, when: _____________________
Is the client homeless? Yes___ No_____
CURRENT SUBSTANCE USE:
Substance
Method of Ingestion
Amount
Frequency
Age of onset
Last Use
Please circle current withdrawal symptoms:
Nausea
vomiting headache diarrhea
body aches fever stomach cramps muscle cramps
Muscle twitching shaking increased heart rate insomnia anxiety depression irritability chills
Sweating chills anorexia itching electric sensations runny nose yawning sneezing seizure activity
Is client ambulatory and able to ascend and descend stairs? Yes ____ No ____
Prior Treatment (list # of treatment episodes/treatment type/if completed: __________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
MEDICAL:
Doctor’s Name/Phone Number: ___________________________________________________________________________
Is the client pregnant? Yes ____ No ____ If yes, due date: _________________
Any known medical problems/concerns (hypertension/diabetes/seizure disorder/history of seizures/stroke/heart attack/chronic
pain/HIV/hepatitis)? If so, explain: _____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Names/Doses of any medications: MUST HAVE 30 DAY SUPPLY
Name of Medication
Dosage
Frequency
Reason
When prescribed/by whom
Mental Health:
Does client have a psychiatric diagnosis or other behavioral health concerns? If yes, explain: __________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________
Is client currently receiving mental health care? Yes __ No __ If yes, where and with whom? ______________________________
_________________________________________________________________________________________________________
Is client expressing any suicidal ideation, intent, or intent with plan?
Yes ____ No ____
Is client expressing any homicidal ideation, intent, or intent with plan? Yes ____ No _____
Has client ever attempted suicide? Yes ____ No ____ Has client ever attempted homicide? Yes ____ No ____
If yes, to either question, date of last episode, and an explanation of the episode:
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
LEGAL:
Is client on Probation/Parole? Yes ___ No ___
If yes, list reason and the name, phone number and parish of officer: _________________________________________________
Name of Probation/Parole Officer
Phone Number
Address
Parish
Does client have any pending court dates? Yes ____ No ____
If yes, reason, when, and where:____________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________
Is the client involved with the Department of Children and Family Services? Yes ____ No ____
If yes, list reason, name of worker, phone number, and parish: ______________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________
PLEASE COMPLETE AND ATTACH RELEASE OF INFORMATION DOCUMENTATION. THANK YOU
FAX to: ADMISSIONS: 504-324-4731
OR
Back-up#: 504-371-5029 ATTENTION ADMISSIONS
_______________________________________________
____________________________
Signature of person completing form
Date
Revised 4-14-2014