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

  • Date of Birth*
     / /
  • What is your gender identity (select all that apply):*
  • Please share your pronouns you would like us to use when referring to you. (check all that apply):*
  • Format: (000) 000-0000.
  • 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
  • Have you ever been in any of our services before?

  • The following questions are intended to determine your eligibility for government funding in the event that you are not eligible for Oregon Medicaid. We will need proof of income and household size to determine if you qualify.

  • Legal

  • Have you (the patient) been charged with a sex related offense or arson?*
  • Do you (the patient)have a parole/probation officer?*
  • Are you (the patient) involved in any restraining orders or no contact orders*
  • Will you (the patient) need interpretive services?
  • Are you a family member of or a Friend of the patient?

  • 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?

  • Community Partner Referral

    Referring someone else

  • Contact information for person making referral

  • Format: (000) 000-0000.
  • Will you continue working with this patient if admitted to residential and/or after their discharge?
  • If we have additional questions about this patient, what is the best way to contact you?
  • Are there other supportive contacts for the patient?

  • Please submit an ROI and the person's name and contact information below.

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  • Is the patient currently incarcerated, hospitalized, in withdrawal management, rapid access center?
  • What is their projected release/discharge date:
     - -
  • Is this a hospital referral/is the patient currently hospitalized?*

  • 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
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  • Anticipated Discharge Date:
     - -
  • Where is the patient discharging to?
  • Are you hoping to transfer the patient from your services directly to Fora?*
  • Are any follow-up appointments scheduled?
  • Other Factors impacting patient's health: (select all that apply)
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  • Medical and Mental Health:

  • Do you (the patient) need assistance performing activities of daily living (ADLs)*
  • Do you (the patient) have any medical conditions or concerns?*
  • Are you (the patient) taking any medications? (If hospital referral, please list medications that will be continued after discharge)*
  • Do current medications include any of the following? (Select all that apply):
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  • 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?

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  • Do you (the patient) have a primary care provider (Strongly preferred)?*
  • Have you (the patient) had any recent seizures or have ongoing seizure disorders or concerns?*
  • Do you (the patient) have any special care needs? (select all that apply)
  • Are you (the patient) pregnant?*
  • Please provide your estimated due date.*
     - -
  • Have you (the patient) had more than 3 visits to the ER in the last 6 months? (other than current hospitalization if applicable)*
  • Have you (the patient) been hospitalized for any medical or mental health reasons in the last 6 months?*
  • Do you (the patient) have any mental health conditions or concerns?*
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  • Are you (the patient) currently connected with psychiatric prescribing or outpatient mental health services?*
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  • Have you (the patient) had a suicide attempt in the last month? (Not automatically disqualifying but does require additional information)*

  • 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

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  • 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?*
  • I, (the patient), acknowledges that visitors and attending outside may not be available during the first 30 days of treatment.

  • 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.
  • Should be Empty: