GHC-SCW Foundations IOP External Referral Form

GHC-SCW Foundations IOP External Referral Form
Thank you for referring your patient to GHC-SCW Foundations IOP. Our program is located at our Sauk Trails Clinic location. Hours are Monday through Friday 9 a.m.-12 p.m. and 1:30 p.m.-4:30 p.m. Our program treats adults with general behavioral health concerns. Program content includes psychiatric assessment, CBT and DBT group therapies and individual therapy.
Demographic Information
Date of Referral

MonthDayYear
Date
Name of Patient*
Pronouns
Patient's Legal Sex*
Patient's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient's Date of Birth*

MonthDayYear
Date
Insurance Information
Insurance Company*
ID #*
Group #
Subscriber Name
Subscriber Date of Birth

MonthDayYear
Date
Phone Number to Verify Benefits
Please enter a valid phone number.Format: (000) 000-0000.
Is the patient a GHC-SCW employee or family of a GHC-SCW employee? *
Please enter: Yes, No or Unknown
Referral Source
Referring Provider Name*
Referring Provider NPI*
Referring Agency*
Referring Provider Email*
example@example.com
Referring Provider Phone*
Format: (000) 000-0000.
Length of Treatment Relationship
Date of Most Recent Visit

MonthDayYear
Date
Clinical Information
Provide a brief description of the patient's current symptoms, functional impairment and reason why needs are best met at IOP level of care.*
Provide a description of recent safety concerns including non-suicidal self-injurious behaviors, suicide behaviors or attempts, risk taking behaviors, inability to care for self and aggression or threats to others.*
Clinical Goals
Primary Goal*
Secondary Goal*
Current Behavioral Health Diagnosis and ICD 10 Code
1*
2
3
4
5
Has the patient agreed to participate in GHC Foundations IOP if accepted?*
Is the patient likely to be able to maintain safety with IOP level of support?*
Is substance use an active concern?*
Is an eating disorder an active concern?*
What treatment alternatives to IOP have been or are being considered?
Previous Mental Health Treatment Programs (include hospitalizations, PHP/IOP, outpatient and substance use treatments)
1*
2
3
4
5
6
Substance Use (current and history of problematic use)
Alcohol*
Tobacco
Drugs*
Caffeine
List all current medications (name, dose and frequency)*
Medication allergies and adverse reactions
Is the patient compliant with medications? If not, what are identified barriers?*
What medication adjustments or changes are deemed necessary?
Past Medical History*
Any other pertinent social or trauma information.*
Current Outpatient Providers
Psychiatrist*
Therapist*
Dietician
Primary Care*
Other
Current Outpatient Treatment
Anticipated Prescriber at Discharge
Comments/Other Relevant Information
If you are a provider and have questions, please contact us at: (608) 662-5071
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GHC-SCW Foundations IOP External Referral Form

Demographic Information

Insurance Information

Referral Source

Clinical Information

Clinical Goals

Current Behavioral Health Diagnosis and ICD 10 Code

Previous Mental Health Treatment Programs (include hospitalizations, PHP/IOP, outpatient and substance use treatments)

Substance Use (current and history of problematic use)

Current Outpatient Providers

Current Outpatient Treatment

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