PHP/IOP Self-Referral Form- Outpatient

PHP/IOP 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
Gender Identity
Sex Assigned at Birth
Pronouns
Preferred Name
Social Security#*
Translator Needed?

YesNo
Guardian Conservator If Applicable
Mailing Address*
Street Address if different
City*
State*
Zip Code*
*Phone #*
Email*
example@example.com
May we leave a message on the phone # above?*

YesNo
Check the boxes that most accurately describe your ethnic origin:*

Mexican, Mexican American, Chicano/aNot HispanicPuerto RicanOther Hispanic OriginCubanDecline to answer
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 IslanderSamoanVietnameseWhiteDecline to answer
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
LEVEL OF SERVICE
Services: What services are you requesting?*

Virtual Partial Hospital ProgramVirtual Intensive Hospital ProgramHealthcare Professionals & First Responders (HPFR)
WHO ARE YOUR CURRENT TREATMENT PROVIDERS
Please list your current care providers:
Therapist Counselor
Psychiatrist
Primary Care
MAT Provider
Case Manager
PRESENTING PROBLEMS
Do you have access to a computer or tablet with a webcam and in-home internet connection?*

YesNo
Do you have access to a private space for the duration of daily programming (3-5 hours weekdays for 4-6 weeks)?*

YesNo
Briefly describe the mental health problems you are currently experiencing*
What are your goals for treatment?*
Are you currently experiencing any of the following?*

Suicidal IdeationSelf Injurious BehaviorHomicidal IdeationSubstance UseNone
Additional comments:
Any other information that is important for us to know?
File Upload (Optional: Include information that you may have received from your provider or a recent healthcare setting visit)

Cancelof
A member of our Practice Management Team will reach out to confirm receipt of this referral and gather any missing information necessary for processing.
Should be Empty:

PHP/IOP SELF-REFERRAL FORM-Outpatient Clinic Services

INSURANCE INFORMATION

LEVEL OF SERVICE

WHO ARE YOUR CURRENT TREATMENT PROVIDERS

PRESENTING PROBLEMS