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Geriatric Regional Assessment Team Referral Form


Before completing this form, you attest to the best of your knowledge that the person being referred:
  • is not actively stating a plan and intent for suicide or assault on another person
  • is not in need of emergency medical or behavioral health care

Please complete all sections

Person referred for outreach and assessment






Address for outreach











Outreach Coordination
Anyone to contact (besides referent) who will coordinate outreach?



Presenting Problem/Reason For Referral
This referral must describe some behavioral issue related to mental health, substance use, or cognition/memory to be assessed by GRAT.


Safety Concerns




Referring Source
Please leave a direct number or email to be reached at for further questions.







POA



More POA contacts can be added at the bottom of this page
Family / Support



More Family/Support contacts can be added at the bottom of this page
Primary Physician



More Physician contacts can be added at the bottom of this page
Other Healthcare Providers



More Healthcare Provider contacts can be added at the bottom of this page
Other Providers
Please complete if referred person is receiving services from any other social service agencies




Additional contacts (POA, Family/Supportive, Physician, Healthcare Providers, Other Providers)