TotalPath Behavioral and Recovery

TotalPath Behavioral and Recovery

For the Total me health and wellness clinic
We appreciate your interest in TotalPath Behavioral & Recovery PHP/IOP/OP outpatient day treatment programs!

To get a sense of our PHP/IOP for adults, we invite you to learn more about the program, experience a day in the life of the program, and view our daily group therapy schedule.

Key things to know:
- Our Partial Hospitalization (PHP) and Intensive Outpatient (IOP) are intensive group-based treatments for adults 18 and over who are in crisis.
- Patients attend multiple groups a day on weekdays, while also receiving individual therapy and psychiatry.
- We offer on-site, remote (Zoom), and a hybrid mix of both.
- We do not offer outpatient therapy or psychiatry. We do not have an adolescent PHP or IOP.
- We offer a free and ongoing weekly aftercare group for PHP/IOP graduates.
- We take most major insurance except Medi-Cal. Kaiser members must be referred directly via your Kaiser providers.
- This form is confidential and HIPAA-compliant.
- If you have a question about billing for an existing or past case, please complete this form for the fastest response.
Please note that this form is fully secure, confidential, and HIPAA compliant.
Our program is entirely voluntary and depends on personal motivation for success. As such, we no longer accept referrals from friends and family. Instead, we require self-referral by the adult seeking and consenting to treatment, or else professional referral by an actively involved medical or mental health professional.
Who are you interested in referring to our PHP/IOP?
Thank you for referring a patient under your care! We will gather your information here and then collect the prospective patient's information in the next section.
Hospital/Facility/Program Name
Referring Provider's Name
Referring Provider's Email
example@example.com
Referring Provider's Direct Dial Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referring Provider's Relationship to Patient
Referring Provider's Name
Referring Provider's Email
example@example.com
Referring Provider's Direct Dial Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referring Provider's Relationship to Patient
Name of Discharge/Records Coordinator
Phone of Discharge/Records Coordinator
Please enter a valid phone number.Format: (000) 000-0000.
Email of Discharge/Records Coordinator
example@example.com
Fax of Discharge/Records Coordinator
How did you find TotalPath Behavioral & Recovery PHP/IOP/OP?

Other
REFERRAL DETAILS
Prospective Patient's Full Legal Name
Prospective Patient's Chosen First Name or Nickname
Prospective Patient's Primary Email Address
example@example.com
Prospective Patient's Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Prospective Patient's Date of Birth (MM/DD/YYYY)

MonthDayYear
Our program is for adults 18 years old and up.
Prospective Patient's Primary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prospective Patient's Gender

Other
Prospective Patient's Pronouns

Other
MEDICAL INSURANCE INFORMATION
Is the person seeking treatment covered by Medicare or Medicaid?
Prospective Patient's Primary Insurance

Other
Do you have photos or scans of the prospective patient's insurance card (front and back) that you could upload here?
Primary Insurance Card (photo of front)

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Primary Insurance Card (photo of back)

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Prospective Patient's Insurance ID Number
Phone Number for MEMBERS on Back of Insurance Card
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number for HEALTHCARE PROVIDERS on Back of Insurance Card
Please enter a valid phone number.Format: (000) 000-0000.
MEDICAL RECORDS AND INFORMATION
- If you have pertinent medical records -- referral paperwork, recent labs, hospital discharge summaries, etc. -- you can securely send those to us below via our HIPAA-compliant file delivery system.
- You can also securely fax us records and more at 956-304-3221.
Medical Records 1

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Medical Records 2

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Medical Records 3

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Medical Records 4

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Obtaining Other Medical Records
Due to the high volume of referrals and admission inquiries, we may take up to 5 days to respond to your request. Completing this form is always the best and fastest way to reach us!

For Health plan referring providers, please contact your call center to send us the referral, and Admissions will reach back out to you directly.

For self-referring adults: By clicking submit I consent to being contacted by the admissions department by phone or email and understand it is my responsibility to respond to them in a timely manner. Please check your email.
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TotalPath Behavioral and Recovery

REFERRAL DETAILS

MEDICAL INSURANCE INFORMATION

MEDICAL RECORDS AND INFORMATION