Referral

Our hearts and homes welcome you…

Each and every smile is priceless.

For Referrals, please email Rosie at rosie@paraserv.org

Thanks for your interest in Paradigm.

If you would like to do a referral, please feel free to complete this online form to submit directly to us via secured email. Along with submitting this referral, please fax/mail most recent Medications, Psychiatric Evaluation, Social History and Neurological/Psychological Evaluation if available. Physical and Mantoux are required within 30 days prior to admission.

To complete a referral form offline, click here to download the referral form (PDF) which will give you access to a printable form for you to complete and fax/mail to us.

EMAIL ADDRESS: (required)

NAME (First, Middle, Last) (required)

GENDER (required)

PRESENT ADDRESS (required)

SOCIAL SECURITY NUMBER WILL BE REQUESTED UPON REVIEW. PLEASE PROVIDE A TELEPHONE NUMBER WHERE WE MAY CONTACT YOU TO OBTAIN THIS INFORMATION (required)

DATE OF BIRTH (required)

PHONE NUMBER (required)

M.A. NUMBER (required)

WAIVER? (required)

CASE MANAGER (required)

CASE MANAGER ADDRESS/PHONE (required)

COUNTY OF RESPONSIBILITY (required)

PSYCHIATRIST (required)

PSYCHIATRIST ADDRESS/PHONE (required)

DIAGNOSIS (required)

INPATIENT NON STATE HOSPITAL ADMISSION (DURING THE PAST 3 YEARS) (required)

DAY TREATMENT INVOLVEMENT (required)

VOCATIONAL INVOLVEMENT (required)

CURRENT SERVICE PROVIDER/CONTACT PERSON (required)

ADDRESS/PHONE (required)

IS CLIENT CURRENTLY UNDER COMMITMENT? (required)

IF YES, EXPIRATION DATE (required)

GUARDIANSHIP (required)

REP PAYEE (required)

FUNDING SOURCE (required)

AMOUNT (required)

COMMUNITY INTEGRATION

MEDICATION MONITORING/EDUCATION

BEHAVIOR MANAGEMENT (VERBAL/PHYSICAL AGGRESSION)

INDEPENDENT LIVING SKILLS

SYMPTOMS MANAGEMENT

MOBILITY STATUS

SELF-CARE (ADL’S)

GENDER/SEXUAL ISSUES

VOCATIONAL FUNCTIONING

SOCIAL FUNCTIONING

SUBSTANCE ABUSE

MEDICAL/DENTAL NEEDS (SPECIAL DIET)

DOES THE CLIENT KNOW OF THIS REFERRAL? (required)

REFERRED BY NAME/PHONE NUMBER (required)

DATE FORM COMPLETED (required)