Behavioral Health Services Referral Form
Please fill-out the form as completely as possible.
Referral Source Information
Date of Referral
*
/
Month
/
Day
Year
Date
Referring Provider Name
*
Organization
*
Contact Phone Number
*
-
Area Code
Phone Number
Referring Provider Email
example@example.com
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Patient Demographic Information
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone Number
*
-
Area Code
Phone Number
Mobile Phone Number
-
Area Code
Phone Number
Patient Email
example@example.com
Gender Identity
Female
Male
Transgender Female
Transgender Male
Gender Variant/Non-Conforming
Prefer Not to Answer
Insurance Type
*
Insurance Policy/ID Number
*
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Behavioral Health Information
Reason for Referral
*
Diagnosis (
list confirmed if known, if not suspected
)
Primary Psychiatric Diagnosis
Secondary Psychiatric Diagnosis (including substance abuse)
Relevant Medical Diagnosis
Relevant Social Factors
History of Violence
Yes
No
If Yes, details please
History of Suicide Attempts
Yes
No
If Yes, details please
History of Psychiatric Hospitalizations
Yes
No
If Yes, details please
Previous Symptoms and Diagnosis
Current Psychiatric History and Treatment
Current Symptoms
Current Suicidal Thoughts
*
Yes
No
If Yes to Current Suicidal Thoughts, Please Explain
Current Homicidal Thoughts
*
Yes
No
If Yes to Current Homicidal Thoughts, Please Explain
Does Patient Have a Current Mental Health Provider
Yes
No
If Yes Details please
Current Psychiatric Medications
Any Additional Information
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