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Extreme Counseling Solutions, Inc.
Referral For Mental Health Skill Building

Yes No
Yes No
1. Has difficulty in establishing or maintaining normal interpersonal relationships to such a degree that he/she is at risk of hospitalization, homelessness, or isolation from social supports as evidenced by:
2. Requires help in basic living skills such as maintaining personal hygiene, preparing food and maintaining adequate nutrition or managing finances to such a degree that health or safety is jeopardized as evidenced by:
Personal Hygiene Food Preparation
Nutritional/Dietary Maintenance Housekeeping
Health and Safety Medication Management
Money Management Social Skills
3. Exhibits such inappropriate behavior that repeated interventions by the mental health, social service, or judicial systems are necessary as evidenced by:
4. Exhibits difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior as evidenced by:
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