AOT Referral Form

Assisted Outpatient (AOT) Referral Form

Identifying Data

Name

Alias/Maiden

Preferred Pronouns

They/Them

She/Her

He/Him

SS#

DOB

Current Phone

Street Address

City

Zip

Insurance Type

Policy Number

Veteran?

Yes

Emergency Contact

Name

Relationship

Street Address

City

Current Phone

Nearest Relative

Advanced Directives?

Yes

Referring Agent

Name

Title

Relationship

Signature

Psychiatric Information

Providers

Therapist

Clinic

Psychiatrist

Clinic

Diagnosis

Axis I

Axis II

Axis III

Axis IV

Code

Current Psychiatric Medications

Press "+" to add more.

Name

Dose

Medical Providers

Medical Doctor

Comments

Specialist

Comments

Other

Comments

AOT Eligibility Criteria

A person may be considered for an AOT if they meet ALL of the following criteria: (PLEASE VERIFY)

Is at least 18 years of age and suffers from a mental illness

Yes

Is unlikely to survive in the community without supervision

Yes

Describe.

Has a history of NON-COMPLIANCE with treatment for mental illness which has led to either 2 hospitalizations for mental illness in 36 months, or resulted in at least 1 act of violence towards self or others, or threats of serious physical harm to self or others, within 48 months.

Yes

Please provide dates and locations of hospitalizations and/or incarcerations.

Is unlikely to accept the treatment recommended in the treatment plan.

Yes

Describe the client's refusal to accept treatment.

Is in need of AOT toa void relapse or deterioration that would likely result in serious harm to self or others.

Yes

Abuse, assaultive behavior, weapons, threats, document all history of violence to self or others, history of non-compliance with necessary medical treatment which places the individual at significant medical risk.

Describe.

Alerts

Complete referral form in as much detail as possible. Referrals that are incomplete or that do not provide sufficient detail will be returned for additional information.

Additional Information

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Identifying Data

Emergency Contact

Referring Agent

Other Current/Past Providers

Psychiatric Information

Providers

Diagnosis

Current Psychiatric Medications

Medical Providers

AOT Eligibility Criteria

Alerts

Official websites use .gov.

Secure .gov websites use HTTPS.

Community Development

General Services

Human Services

Public Safety

Public Works

AOT Referral Form

Identifying Data

Emergency Contact

Referring Agent

Other Current/Past Providers

Psychiatric Information

Providers

Diagnosis

Current Psychiatric Medications

Medical Providers

AOT Eligibility Criteria

Alerts