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Age

Diagnosis

POA Name/Relationship/Phone #

Facility Name and Room #

Reasons For Referral

Physical

Patient is anxious

Patient has pain with marked anxiety component

Patient has difficulty sleeping

Patient has respiratory distress

Psychological/Emotional

Patient is distressed, fearful, withdrawn, grieving, or anxious

Patient is reminiscing, evaluating life

Patient has used creative means of expression in past

Social

Patient is isolated

Patient and family members have strained or difficult relationships

Family members need support

There is staff/patient stress

Spiritual

Patient's faith is important

Patient questions meaning of life

Recreational

Patient is bored or lonely

Patient loves music

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