BHC Referral Form
Demographic Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Patient SSN:
Patient Marital Status
Patient Language
Gender
Male
Female
Other
Race
Military
Military History?
Yes
No
Military Benefits?
Yes
No
Living Situation
Adress Type
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Referral
Referral Source
Name
First Name
Last Name
Agency or entity referring client:
Phone Number
Please enter a valid phone number.
Reason for client’s visit with referring agency:
Reason for discharge at referring agency:
What services is the client seeking?
Mental Health
Substance Use
Housing
PRP
Psychiatric
Is client currently enrolled in another program?
Yes
No
Please select all that apply
Mental Health
Substance Use
PRP
Methadone
Suboxone
Any prescribed medications? If Yes, list.
Date of last refill and how many?
Back
Next
Insurance
Does the client have active insurance?
Medicare
Medicaid
Self Pay
Policy Number
Group Number
Eff Date
-
Month
-
Day
Year
Date
BHC Housing Criteria
Registered Sex Offender
Yes
No
History of fire Setting
Yes
No
Does the client have any issues with mobility that would interfere with his ability to walk up to aMile
Yes
No
Does the client have any open wounds
Yes
No
History of Seizures
Yes
No
If so, when was the last episode and are they currently taking any preventive medication
Submit
Should be Empty: