Psychiatric Referral Form (Page 2 of 2) in pdf

Psychiatric Referral Form Page 2

A COPY OF IMMUNIZATION RECORDS ARE REQUIRED WITH THIS REFERRAL

Page 2 of 2

PSYCHIATRIC REFERRAL

Student Name ________________________________________

D.O.B __________________________

PSYCHIATRIST: A request for Home Instruction has been made for the above-named student. The California Education

Code §44873 requires that a licensed California physician file a statement which includes a medical diagnosis.

Attending Psychiatrist’s Statement

Is student capable of attending classes on his/her school campus now, with accommodations to meet

□

their emotional needs?

Yes

If yes, please list accommodations:

If no, please complete the information below:

DSM IV Diagnosis:

Summary of Therapeutic Plan:

What medication(s) is/are the student currently prescribed?

□

Is the student a danger to self or others:

Yes

Explain:

Why is the student unable to attend school?

What aspects of the treatment plan are being implemented to enable the student to return to school?

□

Estimated date student may return to school: __________________________________

Part time

Full

time (Referral not to exceed

days)

Physician’s Signature ______________________________________ M.D.

Date ___________________

Physician’s Name (Print) _______________________________ M.D. Phone: (

) __________________

Fax: (

) __________________

Address____________________________________ City______________________ Zip ______________

C:/Documents and Settings/lauds_user/Desktop/REFERRALS

Psychiatric Referral Form Page 2