Residential Interest Form v2

Residential Interest Form

Residential Online Referral
Instructions: Please complete this form and upload relevant records. Not having records can delay our review of a person's eligibility.

If you think you meet denial criteria, Please complete the form as we determine eligibility on an individual basis and will likely ask for more information
Important Program Information

Residential patients live in a dormitory-style setting located at our Cherry Blossom location in SE Portland. The length of treatment depends on a person’s use history, recovery goals, progress and readiness. The residential program is a minimum of 90 days. Completion is based on assessment of skill development, treatment engagement, and successful progress through the three phases of treatment.

Individuals in residence are assigned a Certified Alcohol and Drug Counselor and/or a Dual-Diagnosis Counselor. Patients participate in groups that provide education and skill-building; helping to understand their disorders, triggers, and how to build better habits and relationships.

We should note that Fora Health is a tobacco and nicotine product-free facility. This includes outdoor areas. We offer smoking cessation services and Nicotine Replacement Therapy.
Basic Patient Information
Name*

First name (Exactly it appears on your insurance card)Last Name (Exactly it appears on your insurance card)
Name

Preferred First NamePreferred Last Name
Date of Birth*
Gender*
Date of Birth*

MonthDayYear
Date
What is your gender identity (select all that apply):*

Agender/without genderCisgenderDemigenderTransgender Female/trans woman/affirmed womanTransgender Male/trans man/affirmed manNon-binaryGenderqueerManWomanTwo-spiritAnother gender identity not listedI do not want to share my gender identity
Please share your pronouns you would like us to use when referring to you. (check all that apply):*

He/Him/HisShe/her/hersThey/them/theirsIt/itsZe/Zir/ZirsXie/hir/hirsAny pronounsNo pronounsOther pronouns not listedI do not want to share any pronouns
Race
Ethnicity
SSN (Optional)
Note: Not providing this information may delay the admissions process.
Preferred contact method*
Phone Number
Email
example@example.com
We may contact you via email or text, If you do NOT want to be contacted via text or email, please check the boxes below

I do NOT want to be contacted via textI do NOT want to be contacted via email
Have you ever been in any of our services before?

YesNo
What is your reason for wanting residential treatment?
Insurance Plan*
Insurance ID Number
Please explain
Legal
Have you (the patient) been charged with a sex related offense or arson?*

YesNoUnknown
Please specify.*
Do you (the patient)have a parole/probation officer?*

YesNoUnknown
Please specify their name and county and contact info.
Are you (the patient) involved in any restraining orders or no contact orders*

YesNo
Please specify.
Name of individuals involved, etc.
Will you (the patient) need interpretive services?

YesNo
Please describe
ASL, Español, etc...
Are you a family member of or a Friend of the patient?

YesNo
ATTENTION

Only Referring Partners or Patients are authorized to submit this form.

Please have the patient fill out and submit the form.
Are you a part of an agency or organization that is submitting this referral for a patient?

YesNo
Community Partner Referral

Referring someone else
Name of referring organization *
Relation to individual *
e.g. Case Manager, Primary Provider, etc.
Name of person making referral*
Name of person making referral*
Contact information for person making referral
Phone Number
Please enter a valid phone number.
Email
example@example.com
Will you continue working with this patient if admitted to residential and/or after their discharge?

YesNo
What is the best way to contact this patient?*
If we have additional questions about this patient, what is the best way to contact you?

CallEmail
Are there other supportive contacts for the patient?

YesNo
Please submit an ROI and the person's name and contact information below.
Name
Contact information
Option to upload an ROI and collateral documents

Please upload an ROI and any additional relevant information you would like us to review. Without an ROI we will be unable to contact you further about this referral. If you do not have records at this time. You can send them to us when you have them at Fax# 503-535-1163 or Referrals@forahealth.org
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Is the patient currently incarcerated, hospitalized, in withdrawal management, rapid access center?

IncarceratedHospitalizedIn Withdrawal ManagementRapid Access CenterOther
What is their projected release/discharge date:

MonthDayYear
Date
If “other” please explain
Is this a hospital referral/is the patient currently hospitalized?*

YesNo
Hospital Referral Details
Please attach the following documents or have records sent to Fax# 503-535-1163 or referrals@forahealth.org

NOTE: not having records may delay our review of a person's eligibility.
- Admission history and physical
- SUD consult note and last 2 progress notes
- Consults and other highly relevant information
- ASAM Assessment within the last year, if available
- Physical Therapy/Occupational Therapy note, if available
- Medication list
- Facesheet
ROI and collateral documents

Please upload an ROI and any additional relevant information you would like us to review. Without an ROI we will be unable to contact you further about this referral. If you do not have records at this time. You can send them to us when you have them at Fax# 503-535-1163 or Referrals@forahealth.org
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Anticipated Discharge Date:

MonthDayYear
Date
Where is the patient discharging to?

HomeUnhousedSNF (please have patient sign ROI for Fora and SNF)Other
Are you hoping to transfer the patient from your services directly to Fora?*

YesNo
If the patient is discharging before they can be transferred to Fora, what is the best way to contact the patient?
Follow-up needs from hospital:
Are any follow-up appointments scheduled?

YesNo
Please include appointments and dates:
Other Factors impacting patient's health: (select all that apply)

UnhousedRace/EthnicityLGBTQIA+Interpersonal ViolenceIV usePregnantOther
If “other” please explain
Option to upload an ROI and collateral documents

Please upload an ROI and any additional relevant information you would like us to review. Without an ROI we will be unable to contact you further about this referral. If you do not have records at this time. You can send them to us when you have them at Fax# 503-535-1163 or Referrals@forahealth.org
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Medical and Mental Health:
Do you (the patient) need assistance performing activities of daily living (ADLs)*

Yes (please attach physical therapy/occupational therapy note, if applicable)No
Independence with activities of daily living is required for residential patients. Staff is unable to provide assistance with ADLs. Please provide details about anticipated independence plan and date, if applicable.
Do you (the patient) have any medical conditions or concerns?*

YesNo
Details:*
If checked “attached records” place N/A here
See attached records for details
Are you (the patient) taking any medications? (If hospital referral, please list medications that will be continued after discharge)*

YesNo
Do current medications include any of the following? (Select all that apply):

MethadoneBuprenorphine (Suboxone, Subutex, Sublocade)Other OpioidsPrescriptions stimulants (Adderral, Vyvanse, Ritalin)Benzodiazepines (Ativan, Valium, Clanazopam)Clozapine/Clozaril

If any of your medications are for significant psychiatric conditions or concerns (such as schizophrenia, schizoaffective disorder, bipolar, psychosis, eating disorder, SI, self harm), have there been any medications changes in the last 4 weeks?
YesNo
Please Describe:
Medication list upload (if available)

If you do not have records at this time. You can send them to us when you have them at Fax# 503-535-1163 or referrals@forahealth.org NOTE: Not having records may delay our review of a person's eligibility.
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Do you (the patient) have a primary care provider (Strongly preferred)?*

YesNo
Provider Name
Contact information
Clinic
Have you (the patient) had any recent seizures or have ongoing seizure disorders or concerns?*

YesNo
Please describe:*
Do you (the patient) have any special care needs? (select all that apply)

IV MedicationsWound CareCurrent Physical Therapy/Occupational TherapyCognitive needsSpecial nutrition or dietary needs
Please provide details*
Are you (the patient) pregnant?*

YesNo
Please provide your estimated due date.*

MonthDayYear
Date
Have you (the patient) had more than 3 visits to the ER in the last 6 months? (other than current hospitalization if applicable)*

YesNo
Please provide details*
Include information such as location, dates, and length of stay.
Have you (the patient) been hospitalized for any medical or mental health reasons in the last 6 months?*

YesNo
Please provide details about your hospitalization(s)*
Include information such as location, dates, and length of stay.
Do you (the patient) have any mental health conditions or concerns?*

YesNo

Please share any relevant details about the selected current mental health conditions or concerns*
Please make sure your mental health medications are listed in the Medication list above
Are you (the patient) currently connected with psychiatric prescribing or outpatient mental health services?*

YesNo
Please provide contact information*
Please attach any ROI and Psych notes, if available

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Have you (the patient) had a suicide attempt in the last month? (Not automatically disqualifying but does require additional information)*

YesNo
Please provide additional info*
Help is Available

Speak with someone today!

If you are struggling with thoughts of suicide or wanting to kill yourself, there is help. Please call 911 or the Multnomah County crisis line 503-988-4888, Toll-free:800-716-9769, Hearing-impaired dial:711 if you feel you are in danger.
Use Pattern

Substance use *

	Method of Use	Last Date of Use	Frequency of Use (Daily, Weekly, etc...)
Alcohol
Opioids (Fentanyl, Heroin, etc...)
Benzodiazepines (Ativan, Xanax, etc...)
Meth/Amphetamines
Cocaine/Crack
Other

If “Other” please specify:
Other
Do you (the patient) have any upcoming court dates, legal concerns, warrants for your arrest, family events, surgeries, or other upcoming medical/dental appointments that you need to attend?*

YesNo
Please specify.
Please provide dates and locations, if possible
I, (the patient), acknowledges that visitors and attending outside may not be available during the first 30 days of treatment.

YesNoPatient Not Present (If possible, please inform patient of this information)
Additional program information can be reviewed here

By signing below, I certify, understand, acknowledge and/or agree that:
- Submission of this form does not create a patient-provider relationship with Fora Health and does not guarantee that I will receive treatment by Fora Health.
- Receipt of treatment by Fora Health is subject to availability and Fora Health has the sole discretion to determine whether Fora Health may or may not provide treatment to me.
- Prior to receiving treatment, Fora Health will conduct a detailed assessment and intake to determine whether to provide treatment to me.
- Fora Health is committed to maintaining the confidentiality of information on this form in compliance with applicable law and that I have reviewed Fora Health’s Notice of Privacy Practices located here.
- I am authorized to share information on this form with Fora Health and consent to Fora Health’s use and disclosure of the information on this form to help facilitate my care.
- To the best of my knowledge, information on this form is true, correct, accurate and complete and that false or misleading information may result in my disqualification from treatment or legal consequences.
Acknowledgement of treatment parameters, exclusionary criteria and info needed.

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Acknowledgement of treatment parameters, exclusionary criteria and info needed.

AgreeDisagree
Should be Empty:

	Medication name	Reason	Prescribed by
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10

	Current	In the past
Depression
Anxiety
Bipolar
Schizophrenia
Schizoaffective Disorder
Psychosis
Eating Disorder
PTSD
Self-harm
Suicidal Ideation
Other

Residential Interest Form

Basic Patient Information

Legal

Community Partner Referral

Contact information for person making referral

Hospital Referral Details

Medical and Mental Health:

Use Pattern

Other