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  • ADOLESCENT IOP: EXTERNAL PROVIDER FORM

  • NOTE: If you are experiencing a medical or psychiatric emergency do not fill out this form. Instead dial 911 or contact your primary medical care provider at once.

  • PATIENT INFORMATION

  • DOB:*
     - -
  • Format: (000) 000-0000.
  • May we leave a message with patient information on the preferred phone # above?*

  • GUARDIANSHIP

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • In Vermont, the law allows minors (14-17) to seek outpatient mental health care without the consent of the guardian(s). We will need guardianship consent if our providers recommend medication or therapies other than talk therapy.

  • PRIMARY LANGUAGE

  • Translator Needed?*
  • Check the box that most accurately describes primary language?*

  • ETHNIC ORIGIN

  • Check the boxes that most accurately describe ethnic origin:*

  • PATIENT RACE

  • Check the boxes that most accurately describe race:*

  • INSURANCE INFORMATION

  • DOB:*
     - -
  • Effective Date:*
     - -
  • Expiration Date:
     - -
  • DOB:
     - -
  • Effective Date:
     - -
  • Expiration Date:
     - -
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  • CURRENT PROVIDERS

  • SUBSTANCE USE

  • Are any of the below currently being used?*

  • PRESENTING PROBLEM(S)

  • Does the patient have access to a computer or tablet with a webcam and reliable internet connection?*
  • Does the patient have access to a private space for the duration of daily programming (3-5 consecutive hours)?*
  • Is the patient currently on an Inpatient unit?*
  • Is the patient CURRENTLY experiencing or reporting any of following?*
  • Format: (000) 000-0000.
  • Date:*
     - -
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  • ➤ Submission of the most recent clinical notes to support the referral are required.

  • ➤ Should there be any required information missing, a team member will reach out within 24 business hours to gather the information prior to being able to process the referral.

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  • Should be Empty: