Outpatient Services Referral Form

OUTPATIENT REFERRAL FORM (COUNSELING AND MEDICATION MANAGEMENT)
Counties Served: Bedford, Cambria, Clarion, Lehigh, Pike, Somerset, Westmoreland Blair, Carbon& Monroe
Patient Name
Guardians
Address
Email
example@example.com
Mobile
Home
Patient Primary Insurance and ID number
Subscriber name
Patient Secondary Insurance and ID number IF APPLICABLE
(IF APPLICABLE)
Subscriber name
REQUESTING PSYCHIATRIC SERVICES INCLUDING MEDICATION MANAGEMENT

REQUESTING DIAGNOSTIC EVALUATION
Provider
Are current behavioral health services being received? (Yes or No) If yes, please describe Behavioral Health services current being received:
Are Behavioral Health medications being taken? (Yes or No) If yes, please list provider of medications.
Please list previous Behavioral Health Treatments.
Most Recent Inpatient Hospitalization
Location of Hospitalzation
Reason for Most Recent Admission
PREVIOUS LONGTERM TREATMENT (RTF, RTFA, LTSR ,STATE HOSPITAL ,DAS)
PREVIOUS OUTPATIENT TREATMENT Including but not limited to: IOP, PHP, COUNSELING ,MEDICATION MANAGEMENT , FAMILY BASED SERVICES, MOBILE THERAPY, etc.)
PREVIOUS ADDITIONAL SERVICES (Including but not limited to: CASE MANAGEMENT, PEER SUPPORT, OTHER)
Should be Empty: