Case Management Referral

Commuity Healing Program

Please correct the errors described below.

Date

Full Name

Email address

Number

Referring Therapist Who does the client see for treatment

Kevnesha Ms. Kym Samiah Alizae Leslie Margarita Kevise Michel

Level of Risk

High:

Recently Released from Incarceration, Recent Psychiatric Hospitalization, Passive SI, Recent Adverse Childhood Experience, Pregnant, Recent Medical Diagnosis, Substance Abuse, Recent Loss of Loved One & in Treatment 2x week

Moderate:

History of SI & Self Harm Behaviors, History of Substance Abuse, History of Incarceration, etc.

Low:

Stable and no Histroy of above

Current Services being Provided

Individual Therapy Group Therapy Paint & Heal: Winning Ways Free Thinkers (Support Group)

Presenting Problem

What is the rationale for case management services

How can case management services support mental health treatment goals?

What support is needed?

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