IRT Referral Form

  • Referral for Intensive Residential Treatment Services

    Please email completed form with service summary and assessment detail to: irt@emerldcity.health

  • Referent Information:

  •  - -
  • Format: (000) 000-0000.

  • Consumer Consent:

  • Has the consumeragreed to be referred to the IRT program?

  • > If yes, please have ther consumer sign a Relase of Information allowing Managed Care organizations to receive the information on this referral and to share information with RI International's IRT Team

    > If not, please obtain consent prior to submitting this form.

  • Consumer Information/Demograhpic:

  •  - -
  • Format: (000) 000-0000.

  • Referral Checklist: Please include all necessary and listed documentations with referral form.

  • ❖ Medical
  • ❖ H&CS/DDA
  • ❖ IF D/C from Hospital Referral
  • ❖ IF DIVERSION REFFERAL
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  • Emerald City Behavioral Health
    Address: 3713 Pacific Ave, Tacoma, WA 98418 Phone: 253-433-7993 Fax: 253-540-6886

  • Release of Information

  •  - -

  • I hereby authorize Emerald City Behavioral Health to release and exchange information regarding my mental health and substance use treatment records with the following individual or organization:

  • Format: (000) 000-0000.
  • The information to be disclosed includes: (initial or write NO)
  • Reason for Disclosure: (initial or write NO)
  •  - -

  • I understand that my treatment records are protected under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts 160 and 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that once information is disclosed, it may be re-disclosed by the recipient and may no longer be
    protected by federal or state law.

  •  - -
  •  - -

  • If the client is unable to sign, please indicate the legal representative's information:

  • Should be Empty: