Referrals

Family/Stakeholder Satisfaction Survey

We strive to provide all of our stakeholders with the highest quality of services and invite your feedback on your experience with GRO.

Please click the link Family/Stakeholder Satisfaction Survey and complete the brief confidential survey. The results of this survey and our improvement strategies will be published in our quarterly Performance Improvement Report posted on our website.

Thank you for your support.

Referral Form (PDF Format) Please complete all of the following if you would prefer to use our online form:
Date of Referral
Consumer informed of Referral:	Yes No
Demographic information:
Consumer Name:
Address:
City:
State:
Zip:
Date of Birth:
Telephone Number:
Social Security Number:
Gender
Race:
Consumer Lives With:
Financial Resources:
Medicaid	Medicare
Private Insurance	None
Social Security Amount
Supplemental Security Income Amount
Retirement Amount:
Payee Name:
VA Amount:
Emergency Information:
Emergency Contact:
Relationship
Telephone Number:
Referral Source Information:
Referred By:
Organization:
Other Agencies/ Family Involved:
Address:
Telephone: (Mandatory)
Fax:
Email:
Reason for Referral:
Immediate/Urgent Needs:
Strength/Skills/Abilities:
Mental Health Information: Please check all that apply.
Hospital Admissions
	3 times in last 12 months
	2 times last 6 months
	60 consecutive days

Name of Hospitals and Hospitalization Admit and Discharge Dates:
Reason for Hospitalization:
Emergency Room Visits and Dates:
Psychiatric Diagnosis:
Axis I: Primary
Axis I: Secondary
Axis II:
Axis III:
Axis IV:
Axis V:
Current Medication(s): (Please include dosage)


PHYSICIAN (S):
Legal History Information:
Status:
Forensic Conditional Release
Outpatient Commitment
Expiration Date:
List Criminal Offenses and Dates
Hearings/Trials Pending and Dates
Probation/Parole Officer Name:
Phone #:
Danger to Self/Others:
Violence Towards Self
Violence Towards Others
Violence Towards Property
Sexual Assault
Fire Setting
Medication non-compliance
Describe:
Check All That Apply: Difficulty with the Following:
Finances
Daily Living Skill Deficits
Transportation
Family Relationships
School/Vocational
Interpersonal Skills
Social, leisure activities
Household Tasks
Describe Relationship with Family:
*A check mark below indicates that consumer, referring professional, and family are in agreement with referral:
Consumer agrees with referral to GRO, Inc.
Consumer Family Member(s) agree with referral to GRO, Inc.
Psychiatrist agrees with referral to GRO, Inc.
Current MH Provider agrees with referral to GRO, Inc.
We strive to screen referrals within 24 - 48 business hours. The assigned Intake Coordinator should contact you within 48 hours to set up an intake appointment.