1
Harlem Bay Network PROS
116 E 124th Street, 3rd Floor
New York, NY 10035
(212) 876-6083
Fax: (212) 876-6092
PROS Referral Form
Applicant Information
Name: _________________________________
Telephone: __________________________
Address: _______________________________
Date of Birth/Age: ____________________
_______________________________
SSN: _______________________________
Race/Ethnicity: __________________________
Able to communicate effectively in English? Yes
Gender:__________ Veteran: Yes
No
No
Preferred Language: ___________
Religion:____________ Income Source(S): ____________________ Foodstamps: Yes
No
Health Insurance(s): ___________________ Policy/CIN Number :_______________________
Marital Status:
Employed:
Y
Highest Level of Education/Degree:
N
If Yes: Full-time
Part Time
Per-Diem/Seasonal
Referral Source:
Name: ________________________
Title/Relationship: _____________________
Agency:_______________________
Phone: ______________________________
Address:
PROS program use only:
 Psych Eval/Diagnosis
 Phys Exam
 Psychosocial
 AOT
I.
Mental Health Information
 Psych Svc
Notes:____________________________
_
PROS program use only:
Date referral received: _______________
Date of intake(s): __________________
_________________________________
Date of admission: __________________
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Mental Health Information
Current/Most Recent Mental Health Provider Name: __________________________________
Agency/Clinic: ________________________________________________________________
Address: ________________________________
Phone: ______________________
________________________________
Diagnosis (applicant must have a primary diagnosis of a serious mental illness to qualify for PROS):
AXIS I/Code or DSM5/Code: _____________________________________________________
AXIS II/Code: _________________________________________________________________
AXIS III/Code: _________________________________________________________________
Other: ________________________________________________________________________
GAF Score: _________
Current Medication (list medication, dosage and dosing interval):
_________________________________________
________________________________________
_________________________________________
________________________________________
_________________________________________
________________________________________
Prescribing Health Professional(s): __________________________Phone: _______________
Will the individual need to receive Psychiatric Clinic services at the PROS program? Yes
No
If Yes was marked above – How much of a psychiatric medication supply does the individual
currently have?
Please indicate the number of psychiatric ER visits in the last 24 months:
Please indicate the number of psychiatric hospitalizations in the last 24 months:
Physical Health Information
Does the individual have a Primary Care Physician: Yes
No
II. listLiving
Situation
If yes, please
name and
contact information of PCP:
Approximately
was the last time the individual visited this PCP?
IV. Livingwhen
Situation
How many ER or hospital admissions has the individual had in the last 6 months for medical
concerns:
3
Living Situation
What is the individual’s current living situation?
How long has the individual been in their current living situation?
Has the individual
ever been Use
homeless?
Yes
No
II.
Substance
Information
If Yes – approximately how many days in the last 6 months has the person been homeless?
Does the individual currently have adult children? Yes
No
Does the individual currently have minor children? Yes
No
If yes – do the minor children reside in the household? Yes
No
If yes, please indicate names and ages:
________________________________________________
___Substance Use Information
Does the individual have an alcohol or other substance use history? Yes
No
If yes, please indicate substances used (including tobacco/cigarette use):
_____________________________________________________________________________
Date of last use of alcohol: ___________________________
Date of last use of other substances:
Date of last use of tobacco:
Legal History
Please list any criminal convictions (please include dates and current status if on parole or probation):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Is the individual under Parole or Probation Supervision?
V.
Recommendations
Does the individual have a current AOT court order? Yes
Yes
No
No
If Yes, would this PROS program be part of the AOT Treatment/Service Plan upon program
admission? Yes
No
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Reason for Referral
Reason(s) for referral to or interest in a PROS program:
Please attach the following Supporting Documents*:
1. Most recent Psychiatric Evaluation containing a primary mental
health diagnosis and a Mental Status Exam (within the last 6
months).
2. Most recent Physical Examination (within the last 6 months).
3. Most recent Biopsychosocial Summary (within the last 6
months).
Signature of referral source: _____________________ Date: __________
*Please note: Omission of supporting documents may delay the
referral/intake process.