Name:

COMMUNITY MISSIONS NIAGARA VISIONS PROS 418 Third St., Niagara Falls, NY 14302 716-205-8708 Screening and Admission Note DOB:

Admission Recommendation A. Admission Criteria 1. 18 years of age or older 2. Functional deficit due to the severity and duration of mental illness B. Admission Decision 1. Admit to PROS a. Reason for Admission

Yes Yes Yes

No No No

Benefit from Community Rehabilitation and Support Services based on the following needs: Benefit from Intensive Rehabilitation or Ongoing Rehabilitation and Support Services based on the following needs: Benefit from Clinic Services based on the following needs: DSM-IV Admitting Diagnosis Narrative Description Axis I Axis II Axis III Axis IV Axis V PROS Professional Staff: Signature: LPHA Signature: Code

_______________________________________ _______________________________________ Based on above information I am recommending this person be admitted to Niagara Visions PROS.

Date: _______ Date: _______

Reason for not admitting to Niagara Visions PROS: Referral: PROS Professional Staff: Signature LPHA _______________________________________ Signature _______________________________________

Date: ________ Date: ________