ELITE CARE SERVICE INC.
111 LAMON ST SUITE 100 FAYETTEVILLE NC 28301
INCOMING PATIENT REFERRAL FORM
Referral Date:
*
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Month
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Day
Year
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TIME:
Hour Minutes
AM
PM
AM/PM Option
Anticipated or Recommended Triage Priority Based on current presentation
Emergent
Routine
Full Name
First Name
Last Name
Date of Birth:
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Month
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Day
Year
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Age at time referral:
Type a question
Primary Phone #:
Secondary Phone #:
Physical Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Evaluations Requested for the following service(s):
Child /Adolescent Mental Health
Comprehensive Clinical Assessment ONLY
Child /Adolescent Substance Use or Abuse
Outpatient Therapy
Adult Mental Health
Medication Management
Adult Substance Use or Abuse
Free Consultation w/ Mini Evaluation
Insurance ID:
Medical Record Number:
OTHER IDENTIFIER FOR INSURANCE VERIFICATION (I.e. SSN):
Self-Pay /Uninsured
Private /Commercial (i.e. BCBS)
Medicaid
Medicare
Name:
Relationship to Individual Referred:
Primary Phone Number:
Secondary Phone Number:
REASON FOR REFERRAL: Please provide specific information of precipitating events that led to this Referral.
The person for whom you are making this referral is willing to Participate in an assessment and treatment recommendations.
Yes
No
Unsure
seeking additional Information
Are there any potential staff safety risks?(Select all that apply.)
Neighborhood safety risks
Weapons in the household
History of suicidal thoughts or attempts
Frequent psychotic episodes
History of homicidal thoughts or attempts
Hostility toward a particular race or sex
Aggressive animals / pets
None
Physician, Name, and Address of Practice:
Phone Number:
Referral Received by BBH on
at
by
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CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION: CRIMINAL JUSTICE SYSTEM REFERRAL
I hereby consent communication between Elite Care Service Inc, TASC, Greater Image (Treatment Program/ Physician/ Other) and NC Department of Adult Correction (Court, Probation, Parole and/or other referring agency)
PLEASE TYPE NAME AS ACKNOWLEDGEMENT
First Name
Last Name
Signature
I understand that this consent will remain in effect and cannot be revoked by me until:
The purpose of and need for the disclosure is to inform the criminal justice agency (les) listed above of my attendance and progress in treatment. The extent of information to be disclosed is my diagnosis, information about my attendance or lack of attendance at treatment sessions, my cooperation with the treatment program, prognosis, and
there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment, or
there has been a formal and effective termination or revocation of my release from confinement, probation, or
parole, or other proceeding under which I was mandated into treatment, or
(Other time when consent can be revoked and/or expires)
I also understand that any disclosure made is bound by Part 2 of Title 42 of the Code of Federal Regulations governing confidentiality of alcohol and drug abuse patient records and that recipients of this information may disclose it only in connection with their official duties.
(Date)
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Month
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Day
Year
Date
(Signature of defendant/patient)
(Signature of parent, guardian or authorized representative if required)
Submit
Distribution: File
Treatment Provider
Offender/Guardian
Should be Empty: