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.

Personal Information
Referral Information

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.

Maximum 3 files.
8 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, sit, svg, zip.
Support Information
Sources of Support
Is client attending school?
Symptoms

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 being 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