External Provider Referral Form-Outpatient Clinic Services

EXTERNAL PROVIDER REFERRAL FORM
IF THE PATIENT IS EXPERIENCING A MEDICAL OR PSYCHIATRIC EMERGENCY, DO NOT FILL OUT THIS FORM. INSTEAD CALL 911, GO TO THE NEAREST ED, OR CALL 988 FOR ADDITIONAL CRISIS RESOURCES.
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
Check the boxes that most accurately describe ethnic origin:*

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

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

American Indian or Alaskan NativeAsian IndianBlack or African AmericanChineseFilipinoGuamanian or ChamorroJapaneseKoreanNative HawaiianOther AsianOther Pacific IslanderSamoanVietnameseWhiteRefuse
Primary Insurance*
Primary Insured Party Name*
DOB*
Relationship to Patient*
Policy*
Group*
If received from the VA, please include authorization #
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
PRESENTING PROBLEM(S): Briefly describe the patient's presenting problem(s) and most recent helpful intervention(s).*
What are the goals for treatment?*
Is the patient CURRENTLY experiencing any of the following?*

DepressionAnxietyTrauma/PTSDPsychosisOCDADHDOtherNone
Is the patient currently on an inpatient unit?*

YesNo
If Yes, what is the discharge date?
Has the patient experienced any of the following in the PAST?*

DepressionAnxietyTrauma/PTSDPsychosisOCDADHDOtherNone
Diagnoses (Psychiatric, Medical, Substance Use, Other)Please list current diagnoses below:*
Is the patient CURRENTLY experiencing or reporting any of following?*

Suicidal IdeationSelf Injurious BehaviorHomicidal IdeationViolence HistoryNone
Any other CURRENT symptoms /behaviors that are important for us to know?*
Tobacco Use

YesNo
Opiods/Opiates (MAT)

YesNo
Alcohol Use (MAT)

YesNo
I AM REFERRING PATIENT FOR THE FOLLOWING PROGRAM

NOTE:

All Inpatient referrals must be sent by Crisis Services and/or an Emergency Department.

Please call 802-258-3700 for more details.

For TMS, please complete the TMS specific referral form.

For Esketamine, please complete the Specialty Medication Clinic specific referral form.
Services: What level of care are you referring to? (Please place separate referrals for each requested service).*

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
Does the patient have a preferred clinician gender?*

YesNoNo Preference
If yes, please explain:
Does the patient have a visit type preference?*

In PersonVirtualNo Preference
Does the patient own or have access to technology (computer, internet service, etc to participate in a remote treatment program?

YesNo
REFERRING PROVIDER
Referred by:*
Practice Name:*
Email address of referring provider:*
example@example.com
Telephone phone #*
To fully process this referral, please fax (802)258-3788 or email outpatient@brattlebororetreat.org a copy of:

1) Most recent medical note

2) Medication history

3) Front and back of the individual's insurance card.

Should there be any required information missing, a Practice Management Team member will reach out within 24 business hours to gather the information prior to being able to process the referral.
Should be Empty:

EXTERNAL PROVIDER REFERRAL FORM

REFERRING PROVIDER