High Utilizer Referral

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Behavioral Health Unit Staff Member Completing Form

First Name

Last Name

Date

High Utilizer Information

First Name

Last Name

Date of Birth

Gender

SSNo

Homeless

Address

City

State

Zip

Phone #

Ethnicity

Race

Collateral Contact

First Name	Last Name	Relationship	Phone

First Name

Last Name

Phone #

Relationship

Add Contact

Client History

History of aggressive behavior

Yes

Unknown

History of suicidal behavior/statements

Yes

Unknown

History of homicidal statements/behavior

Yes

Unknown

History of substance use (other than opioid overdose)

Yes

Unknown

Criminal History

Yes

Pistol License

Negative

Positive

Parole/Probation

Negative

Positive

Orders of Protection

Yes

Unknown

Veteran

Yes

Is this a Mental Health High Utilizer?

Yes

Unknown

Number of PMI calls in 6 months

Number of 911 calls in 6 months

Past 3 Psychiatric Emergencies

Date

Details

Is this an OUD Overdose Referral?

Yes

Overdose Dates and Details

Date	Detail

Other police contact

Additional Comments

Submit