Provider Referral
Please contact us with any questions at 541-485-6340
Interested in ACT services?
Review info & application at
laurel.org/enroll
PROVIDER INFORMATION
Name of Person Completing Referral
*
Include full name
Type of Referring Organization
*
Behavioral Health Provider
Coordinated Care Organization
Hospital
Acute Care or Emergency Department
Peer Support Program
Crisis Center
Primary Care Provider or Medical Home
Substance Use Provider
Name of Referring Organization
*
Phone Number of Person Completing Referral
*
10-digit phone number
Email of Person Completing Referral
*
example@example.com
Your relationship to the individual
*
CLIENT INFORMATION
Client Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender Identity
Legal Gender
*
For insurance purposes
Pronouns
*
Ex: she/her, they/them, etc - If not known, type "unsure"
Does the individual have a guardian?
*
Yes
No
Unknown
Race
*
White/Caucasian
Black/African American
Native Hawaiian/Other Pacific Islander
Asian
American Indian/Alaskan American
Eastern European/Russian
Unknown
Two or More Races
Ethnicity (Hispanic/Latino/a/x/e or Spanish origin
*
Mexican, Mexican American, Chicano/a/x/e
Puerto Rican
Cuban
Other Hispanic, Latino/a/x/e or Spanish origin
Latino/a/x/e combined with racial identities
Not Hispanic, Latino/a/x/e or Spanish origin
Is the individual in need of any translation services?
None
American Sign Language
Spanish
Other
CONTACT INFORMATION
Phone Number of Individual (type N/A if none)
*
Email Address of Individual (type N/A if none)
*
Does the individual consent to Laurel Hill Center providing its name when contacted by phone?
Yes
No
Unsure
Does the individual consent to Laurel Hill Center providing its name when contacted by email?
Yes
No
Unsure
Is the Individual unhoused?
*
Yes
No
Current Housing status
*
Address of Individual
*
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
Insurance Provider
*
Trillium Community Health Plan Medicaid
PacificSource Medicaid
CHOICE Funding
DMAP (Open Card)
Supported Employment Scholarship Funds (only for employment services)
OHP ID #
Note: OHP # is 8 characters in length.
Does this individual also have Medicare?
*
No
Yes
Medicare Insurance Provider
Medicare Policy Number
Note: Without the correct number, LHC cannot process this referral or start services
AVAILABILITY
What are the best days of the week for our staff to contact the individual?
*
Monday
Tuesday
Wednesday
Thursday
Friday
What are the best times of the day to contact the individual?
*
Mornings (8:30AM-12:00PM)
Afternoons (12:00PM-3:00PM)
Early Evenings (3:00PM-5:00PM)
CLINICAL INFORMATION
What is the reason for the referral?
*
Primary Mental Health Diagnosis
*
Secondary Diagnosis(es)
Relevant Social Factors
*
CURRENT PSYCHIATRIC TREATMENT & HISTORY
Current Symptoms
*
In the past 2 weeks (check any that apply):
Suicidal symptoms
Homicidal symptoms
Destruction of property
Does the individual have a current outpatient mental health provider?
*
Yes
No
What services, if any, will remain with the current provider?
Does this individual have current or past criminal justice involvement?
*
Yes
No
Unknown
Past Psychiatric History and Treatment
*
Hx of violence
Hx of suicide attempts
Hx of psychiatric hospitalizations
N/A
Other
Which services are you requesting?
*
Community Based Skills Training
Case Management
Individual Peer Support Services
Supported Employment Services
Supported Education Services
Groups/Resource Center
Are you also requesting medication management?
*
Yes
No
Has the individual agreed to being referred to Laurel Hill Center?
*
Yes
No
Is the individual comfortable discussing their symptoms or diagnosis? If not, please describe the best way to engage the individual about their symptoms and our services?
Additional Information or Comments
ADDITIONAL DOCUMENTATION
Please attach the most recent assessment, treatment plan or crisis notes and ROI if available
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