PHP & IOP External Referral Form

EXTERNAL PHP/IOP REFERRAL FORM-Outpatient Clinic

NOTE: If you are experiencing a medical or psychiatric emergency do not fill out this form. Instead dial 911, go to the nearest ED or call 988 for additional crisis support.
Name*

Legal First NameLegal Last Name
Date of Birth*

MonthDayYear
Date
Previous Names Used
Preferred Name
SS#*
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#?*

YesNo
Check the box that most accurately describe the primary language:*

American Sign LanguageArabicChineseEnglishFrenchGermanHindi/Indic LanguagesItalianRussianSpanishVietnameseOther
Check the box that most accurately describe the ethnic origin:*

No, Not HispanicYes, Mexican, Mexican American, Chicano/aYes, CubanYes, Puerto RicanYes, Other Hispanic OriginRefused
Check the box(es) that most accurately describes the 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 #*
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
I AM REFERRING PATIENT FOR THE FOLLOWING PROGRAMS:

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?*

Virtual Partial Hospital Program (PHP)Virtual Intensive Outpatient Program (IOP)Healthcare Professionals & First Responders (HPFR)
PRESENTING PROBLEM(S)
Briefly describe the patient's presenting problem(s) and most recent helpful intervention(s):*
What are the goals for treatment?*
Does the patient have access to a computer or tablet with a webcam and in-home internet connection?*

YesNo
Does the patient have access to a private space for the duration of daily programming (3-5 consecutive hours)?*

YesNo
Is the patient currently on an Inpatient unit?*

YesNo
If Yes what is the discharge date

MonthDayYear
Date
Diagnoses (Psychiatric, Medical, Substance Use, Other). Please list current and relevant past diagnoses below:*
Is the patient CURRENTLY experiencing or reporting any of following?*

Suicidal IdeationSelf Injurious BehaviorHomicidal IdeationViolence HistoryNone
Additional comments:
Any other CURRENT symptoms/behaviors that are important for us to know?*
Are any of the below currently being used?*

TobaccoAlcoholOpiods/OpiatesOther
Current Providers
Therapist
Psychiatrist
PCP
MAT
Case Manager
Referring Provider Information
Referred by*
Practice Name*
Email address of referring provider*
example@example.com
Phone #*
Date*

MonthDayYear
Date
To fully process this referral, please fax (802)258-3743 or email 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:

PRESENTING PROBLEM(S)

Current Providers

Referring Provider Information