Self-Referral Form- Outpatient Clinic Services

SELF REFERRAL FORM-Outpatient Clinic Services
NOTE: IF YOU ARE EXPERIENCING A MEDICAL OR PSYCHIATRIC EMERGENCY, DO NOT FILL OUT THIS FORM. INSTEAD CALL 911,GO TO THE NEAREST ED, CONTACT YOUR PRIMARY MEDICAL CARE PROVIDER AT ONCE OR CALL 988 FOR ADDITIONAL CRISIS SUPPORT.
Name*

Legal First NameLegal Last Name
DOB*
Previous Names Used
Preferred Name
Social Security#*
Guardian Conservator If Applicable
Mailing Address*
Street Address if different
City*
State*
Zip Code*
*Phone #*
Email
example@example.com
Preferred Method of Contact*
May we leave a message with patient information on the preferred phone # above?*

YesNo
If not the patient submitting the referral, please clarify who the phone # listed above is for
Check the boxes that most accurately describe your ethnic origin:*

Yes, Mexican, Mexican American, Chicano/aNo, Not HispanicYes, Puerto RicanYes, Other Hispanic OriginRefused
What is your primary language?*

American Sign LanguageArabicChineseEnglishFrenchGermanHindi/Indie LanguagesItalianRussianSpanishVietnameseOther
Check the boxes that most accurately describe your race:*

American Indian or Alaskan NativeAsian IndianBlack or African AmericanChineseFilipinoGuamanian or ChamorroJapaneseKoreanNative HawaiianOther AsianOther Pacific IslanderSamoanVietnameseWhiteRefuse
INSURANCE INFORMATION
Primary Insurance*
Primary Insured Party Name*
DOB*
Relationship to Patient*
Policy*
Group*
Effective Date*

MonthDayYear
Date
Expiration Date*

MonthDayYear
Date
Secondary Insurance
Primary Insured Party Name
DOB
Relationship to Patient
Policy
Group
Effective Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
WHO ARE YOUR CURRENT TREATMENT PROVIDERS
Please list your current care providers:
Primary Care
Therapist Counselor
Psychiatrist
Case Manager
MAT Provider
Other Provider
Please list any psychiatric, medical, substance abuse or other past or present diagnoses:
CURRENT AND PAST HEALTH DIAGNOSES*
Please choose 1 service. If you are seeking more than 1, please contact our staff to discuss options.*

Virtual Partial Hospital ProgramVirtual Intensive Hospital ProgramHealthcare Professionals & First Responders (HPFR)Outpatient Psychiatry (Outpatient Psychotherapy may be deemed a requirement)Outpatient PsychotherapyOutpatient Group Psychotherapy
Group Options:

Women of Aging and Embracing ChangesCoping SkillsStress Management and Coping SkillsContinuing Recovery GroupWomen and Supporting WomenExploring the Self and Relationships
Do you have a preferred clinician gender?*

YesNoNo Preference
If yes, please indicate below:
Do you have a visit type preference?*

In PersonVirtualNo Preference
Briefly describe the mental health and or substance abuse problems you are currently experiencing*
Please describe any substance use disorders and if you are currently using tobacco alcohol cannabis or any prescribed or illicit drugs*
Please describe any history or hospitalization and how recent*
Please describe any history of suicidal and/or self harming behaviors and how recent*
Do you own or have access to the technology (computer, internet service, etc to participate in a remote treatment program?

YesNo
Individual who is submitting the information today:*

SelfSomeone else
If someone else is submitting this referral, please provide the following:
Name of person submitting information*
Relationship*
Your email address*
example@example.com
Your best contact phone*
SELF SUFFICIENCY
Check the boxes that most accurately describe your situation in relation to the following:
Ability to Function

In CrisisVulnerableSafeStableThriving
Housing

In CrisisVulnerableSafeStableThriving
Personal Safety

In CrisisVulnerableSafeStableThriving
Support System

In CrisisVulnerableSafeStableThriving
Mental Health

In CrisisVulnerableSafeStableThriving
Substance Usage

In CrisisVulnerableSafeStableThriving
Should be Empty:

SELF REFERRAL FORM-Outpatient Clinic Services

INSURANCE INFORMATION

WHO ARE YOUR CURRENT TREATMENT PROVIDERS

SELF SUFFICIENCY