Residential Treatment Program

Referral Checklist

Placement Authorization Request Form
Fax completed form to the CBHS Transitions Team at 415-206-4902 for review and approval.

Psychiatric History and Current situation that warrants a residential referral.
The referring clinician should be able to recommend a treatment plan for the client. Include a statement regarding what impairment the client is experiencing that qualifies them for residential treatment.

Physician’s Report for Community Care Facilities or
Physician’s Report for Community Care Facilities for the Elderly

(Required for the Seniors/Rypins’ Program)

  • Fill out a Restricted Health Care Plan if client has these health needs: Inhalation assisted devices, colostomy/ileostomies, catheters, staff or other communicable infections, insulin-dependent diabetes, stage 1 & 2 ulcers, wounds, gastronomies, tracheostomies
  • Ambulatory Status:
    • Non-ambulatory means person unable to leave a building unassisted under emergency conditions. This also includes a person who is unable to likely physically or mentally respond to a sensory signal. This also includes persons who depend upon mechanical aids such crutches, walkers, and wheelchair.
    • For non-ambulatory referrals, please specify in order to place client in most appropriate program. Client must have ability to transfer to and from wheelchair on their own. Program staff cannot provide medical care.

PPD (within the last 6 months) or Chest X-Ray (no more than a year old).

Medication Orders (signed by the prescribing doctor).
If a client is on an IM shot a clear and defined plan must be given as to how treatment will be administered to the client while in the program.

Medication Supply (14 days)

Megan’s Law Verification
Progress Foundation is unable to accept clients who are Registered Sex Offenders under Penal Code § 290.46.

Next Steps:

  1. Complete all documents and fax to Mental Health Triage Coordinator at 415-861-0140.
  2. You can confirm receipt of the referral at 415-861-0828 Ext.138.
  3. The Mental Health Triage Coordinator will contact referent to schedule an assessment and will begin the placement process into a Residential Treatment Program.

We Look Forward to Serving You and Your Loved Ones

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