Mobile Mental Health Treatment (MMHT) Referral Form
Blair, Bedford, Carbon Clearfield, Cambria, Jefferson Monroe, Pike & Somerset Counties
County
*
Date
*
/
Month
/
Day
Year
Date
Referral Source Name
*
Type of Referral: Self Agency Physician Family/Friend, other
Phone
Format: (000) 000-0000.
FacilityAgencyPhysician Making Referral
Referral Name with middle initial
Phone
*
Format: (000) 000-0000.
DOB
*
Insurance
*
SSN
*
Address
*
Physician
Phone
Format: (000) 000-0000.
Last Medical Exam
Psychiatrist
Last Psychiatric Evaluation
Format: (000) 000-0000.
Last Psychiatric Evaluation
Diagnosis
*
Comments
History of Substance Abuse
Inpatient Psychiatric
DA Inpt
History of Incarceration or Parole?
Current Medications
Other AgenciesServices Client is Receiving
Does patient have a history of trauma?
If Yes Action Taken
Referred To (name agency/program)
Please check the criteria that applies to the person you are referring
Medical condition, as documented in the treatment plan, that impairs the ability of the individual to participate or precludes the individual from participating in psychiatric outpatient clinic services.
Submit
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