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Referral form

This referral is being made to (check all that apply)
Identifying Information
Veteran
Name of Contact and Relationship to client
Entitlements
Does individual have a Power of Attorney or Legal Conservator?
Does the individual have a case manager?
Does this consumer have a history of substance abuse?
Medications
Diagnostic Information
Diagnosis 1
Diagnosis 2
Diagnosis 3
Diagnosis 4
Diagnosis 5
Does the individual have any developmental delays or intellectual functioning difficulties?
Does the individual have a history of suicidal, violent or aggressive behavior?
Does the individual have a history of sexually inappropriate behavior?
Has the individual had any involvement with the judicial system?
Is the individual on probation/parole?
Has the individual ever been hospitalized due to their mental illness?
For ALL Housing and SOAR Programs ONLY:
For SSI/SSDI Outreach (SOAR) Only
Has the individual ...
Does the individual expect to be released within 120 days?
Was the individual homeless prior to entering the facility?

Park Center empowers people who have mental illness and substance use disorders to live and work in their communities.

Hope

We believe individuals can be active and contributing members of their community by defining their lives apart from their mental illness

Choice

We believe that individual recovery is possible through loving care, educated choices and support services

Education

We believe that active and ongoing advocacy, education about mental illness and the recovery process are necessary in order to empower members and reduce stigma in our community

Quality

We believe that services should be continuously improved to align with current and emerging best practices