PREVENTION & EARLY INTERVENTION PROGRAM FOR PSYCHOSES (PEPP) REFERRAL FORM

Please review eligibility criteria below prior to completing the referral.

Physicians and Community Providers: Please complete all sections of this form.

Family, Friends or Self Referral; Please complete as much information as you have access to
(Contact info and symptom description are mandatory).

 - Between 16 & 35 years
 - Life time antipsychotic use less than 30 days
 - Symptoms of first episode, psychosis
 - No developmental delay
 - No history of brain injury, epilepsy or other brain disorder.
 - No Methamphetamine Use in last 3 months.

If referral source is Physician or Agency a consult note/relevant information MUST be attached to process referral
You may upload up to three files below.

Please describe in as much detail as possible the symptoms the client is experiencing.  Please consider the following;

  • Hearing voices, seeing odd things that are not visible to others, feeling odd sensation on or in body (Hallucinations)
  • Having unusual ideas that are not grounded in reality. (Delusions)
  • Believing that they can control others thoughts or that their thoughts are bring controlled. (Thought Disorder)
  • Unrealistic paranoia such as worrying about being spied on, conspired against or poisoned (Paranoia)
  • Uncharacteristic changes in their mood.
  • Bizarre or drastic changes in their behavior.
  • Significant changes in sleeping patterns (insomnia).
  • Changes in social habits (isolation, change in peer group)

Tel: 519-685-8500 ext. 71680 Fax: (519)667-6657

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