Adult Referrals Referring Professional or Self-Referral Name* Phone*Client Name* Date of Birth* MM slash DD slash YYYY Client Phone*Other Client PhonePresenting Issues*Symptoms Depression/hopelessness Mood instability/swings Rage/anger Manic episodes Tearfulness Auditory or visual hallucinations Alcohol or drug use Panic attacks or anxiety Obsessions/compulsions Suicidal ideation H/O suicide attempts H/O psychiatric hospitalization All MHC clients receive case management. Are additional services needed? Counseling Psychiatry Medication-Assisted Treatment Is the court involved with this individual/family and requiring feedback on progress and attendance? Yes No Additional CommentsIf you would like to save a copy of this submission for your records, please print this page with referral information BEFORE you submit to MHC. After printing the page, please submit the referral form to MHC’s intake department using the submit button below. Print this page