Referral to Charles Webster Potter Place 1. Please have the C.W. Potter Place referral form filled out by a prospective member's Doctor, Psychiatrist, Therapist, Case Manager, Mass Rehab worker, etc. We encourage the prospective member to be involved in the writing of the referral and to have input into what information is included in it. 2. Upon completion, the referral gets mailed to: Charles Webster Potter Place 15 Vernon Street Waltham, MA 02453 Attention: Program Director Fax to: 781 891.3812 3. When we receive the referral we will call the prospective member to set up a-Guest Day. Guest Days are held on Tuesdays and Thursdays from 9 a.m. -2 p.m. This gives the prospective member an opportunity to be involved in the prevocational work ordered day by spending time in each of the three work areas, along with gaining more information on our vocational and educational supports. The member would also use this as an opportunity to ask questions and fill out some necessary paperwork. 4. The prospective member or referring person must call the Department of Mental Health's Arlington Case Management Office at (781) 641-8100 and tell them you are looking to become eligible for C W: Potter Place services. They will send a separate form for you to fill out. 5. If you already have a DMH Case Manager, you are eligible. 6. When you receive notification about whether or not a member is eligible, please inform the Intake Coordinator at C.W. Potter Place. If you are deemed ineligible, this will not interfere with the member's status. 7. If you have any questions or concerns regarding this process, we encourage you to call the lntake Coordinator at 781 894.5302. 15 Vernon Street, Waltham, MA 02453 Tel: 781.894.5302 Fax: 781.8913812 E-mail: potterplace@msn.com Referral Form C. W. Potter Place Clubhouse Services A Program of the Center for Mental Health and Retardation Services, Inc. Date: _______________________ Member Name _______________________________________________________________ Date of Birth: ________________________________________________________________ Current Address_____________________ Permanent Address: _______________________ _____________________________________________________________________________ _____________________________________________________________________________ Phone Number: _______________________ Referred By: __________________________ Referring Agency: ___________________ Phone: _______________________ PLEASE DESCRIBE REASONS FOR COMING TO POTTER PLACE: • To be involved in the structure of a work ordered day • To improve existing work skills, learn new skills • To get back to work • To work on education • Other: explain: ____________________________________________________________ Please forward the completed referral to: C.W. Potter Place Attention: Program Director Phone: 781 894.5302 15 Vernon Street Fax: 781 891.3812 Waltham, MA 02453 E-mail: potterplace@msn.com For Administration Office Use Only Date Received: _____________________ Date Entered: _______________________ Marital Status: ________________________________________________________________ Gender: __________________________ Social Security #: __________________________ PROVIDERS: Therapist: __________________________ Phone: ___________________________________ DMH Case Manager: _________________ Phone: ___________________________________ House Manager: _____________________ Phone: ___________________________________ Psychiatrist: ________________________ Phone: ___________________________________ Mass. Rehab.: ______________________ Phone: ___________________________________ Legal Guardian: _____________________ Phone: ___________________________________ Address: _______________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Rep. Payee: _________________________ Phone: ___________________________________ Address: _______________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Other: ____________________________ Phone: ___________________________________ DSMIV DIAGNOSIS: Axis I ____________________________ Axis III ___________________________________ Axis II ____________________________ Axis IV ___________________________________ Axis V ___________________________________ Signs/Symptoms of Decompensation: _____________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ MEDICATION: Type Dosage Frequency _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ HISTORY: Family: (significant family members and relevant areas, i.e. mental illness, alcohol/drug abuse, sexual and/or physical abuse) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Psychiatric: (please give a description of when this person began experiencing difficulties and treatment that has occurred) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ History of Suicidal and/or Assaultive Behavior: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Does the person have any legal action pending? If so, please explain. (I.e. probation officer, etc.): _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ History of Alcohol or Drug Abuse: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Allergies and/or Medical Conditions: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Previous Hospitalizations: (please begin with most recent) Hospital Dates Precipitant 1. ___________________________________________________________________________ 2. ___________________________________________________________________________ 3. ___________________________________________________________________________ 4. ___________________________________________________________________________ 5. ___________________________________________________________________________ Previous Day Program Placements: (List most recent first) Type/Name Dates/Duration Reason for Leaving 1. __________________________________________________________________________ 2. __________________________________________________________________________ 3. __________________________________________________________________________ 4. __________________________________________________________________________ Previous Residential Program Placements: (List most recent first) Type/Name Dates/Duration Reason for Leaving 1. __________________________________________________________________________ 2. __________________________________________________________________________ 3. __________________________________________________________________________ 4. __________________________________________________________________________ HEALTH INSURANCE INFORMATION: Medicaid # ________________________________________ Medicare # _____________ Other Insurance: ___________________________________________________________ Company Name: ___________________________________ ID# ____________________ PERSON TO NOTIFY IN CASE OF EMERGENCY: Name: _________________________________________ Relationship: ____________ Address: _____________________________________________________________________ Phone: _______________________________________________________________________ FINANCIAL/INCOME: Source or Income: (please check all that apply): SSI SSDI Family Pension Wages Other If wages or other, please explain: __________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ HOUSING: (please describe current housing situation) _________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ EDUCATION and EMPLOYMENT HISTORY Last Grade Completed: Degree/Cert. Year: Name and location of school: Special Training: ___________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Where: _____________________________________ Year: ________________________ Educational Goals: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Employer Type of Work Dates of Employment Reason for Leaving (List most recent job first; include volunteer work) _________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Special Training: ___________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Where: _____________________________________ Year: ________________________ Employment Goals: ____________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Other Relevant Information: _________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Consumer Signature: _____________________ Date: ______________________________ Signature: ______________________________ Date: ______________________________ Title: ___________________________________ The Center for Mental Health and Retardation Services, Inc. RELEASE TO SEND INFORMATION The standard release of information must be completed and signed by consumer/guardian prior to any request of either verbal or written information. I, , authorize Name of Consumer Name of Organization/Provider to release records to: Charles Webster Potter Place The Center for Mental Health and Retardation Services, Inc. 15 Vernon Street Waltham, MA 02453 The Center for Mental Health and Retardation Services, Inc. Clubhouse Address Consumer Name: _____________________________________________________________ Consumer Signature: __________________________________________________________ Witness: ____________________________________________________________________ Date: _______________________________________________________________________