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The Geriatric/Adult Mental Health Specialty Team (GAST) is a state supported program that provides education, support and resource information to caregivers in the community as well as to staff in long- term care facilities. PBH GAST covers six counties: Cabarrus, Davidson, Rowan, Stanly, Union and Mecklenburg. All services are FREE.
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Inquiry Information
Date [Choose Date]
First Name Last Name
Agency Title
Phone Email
Referral Information
Caregiver First Name Last Name
Address
City County
State Zip
Phone Mobile/Cell
Relationship to Consumer Consumer's Initials
Consumer's Age** Consumer's Diagnosis
**GAST provides service to caregivers in the community of adults age 60 and above who have a mental illness and are at risk of psychiatric hospitalization. If the person being cared for is under age 60 but has geriatric-like needs, the caregiver can also receive GAST services.
Does the consumer have a legal guardian?
If so, please enter the name of the guardian:
First Name Last Name
Phone    
Reason for Referral (symptoms, difficult behaviors / suggestions for needed support):
You agree that the information provided is accurate and not in violaton of HIPAA regulations
GAST 2009 - 2011 | GAST Referral Form | PBH Website
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