ADOLESCENT IOP REFERRAL FORM LEGAL GUARDIAN OR CAREGIVER
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
Legal Name:
*
First Name
Last Name
DOB:
*
-
Month
-
Day
Year
Date
Preferred Pronouns
*
Please Select
He/him/his
He/they
Other
Declined
She/her/hers
She/they
They/them/their
Unable to obtain
If other, please specify below:
Sexual Orientation
*
Please Select
Straight/heterosexual
Questioning
Queer
Asexual
Bisexual
Gay
Lesbian
Pansexual
Decline to answer
Unable to obtain
Other
If other, please specify below:
Gender Identity:
*
Please Select
Male
Female
Non-binary
Transgender woman
Transgender man
Decline to answer
Gender non-conforming
Unable to obtain
Other
If other, please specify below:
Sex Assigned at Birth:
*
Please Select
Male
Female
SS#:
*
Street Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone #:
*
Format: (000) 000-0000.
Email:
*
example@example.com
May we leave a message with patient information on the phone # above?
Yes
No
Legal Guardian/Caregiver:
*
Relationship to Patient:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Legal Guardian/Caregiver:
Relationship to Patient:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
PRIMARY LANGUAGE
Translator Needed?
Yes
No
Check the box that most accurately describes primary language?
*
American Sign Language
Arabic
Chinese
English
French
German
Hindi/Indic languages
Italian
Russian
Spanish
Vietnamese
Other
ETHNIC ORIGIN
Check the boxes that most accurately describe ethnic origin:
*
Not Hispanic
Mexican, Mexican American, Chicano/a
Cuban
Puerto Rican
Other Hispanic Origin
Decline to answer
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CLIENT RACE
Check the boxes that most accurately describe race:
*
American Indian or Alaskan Native
Asian Indian
Black or African American
Chinese
Filipino
Guamanian or Chamorro
Japanese
Korean
Native Hawaiian
Other Asian
Other Pacific Islander
Samoan
Vietnamese
White
Decline to answer
INSURANCE INFORMATION
Primary Insurance:
*
Primary Insured Party Name:
*
DOB:
*
-
Month
-
Day
Year
Date
Relationship to Patient:
*
Policy #:
*
Group #:
*
Effective Date:
-
Month
-
Day
Year
Date
Expiration Date:
-
Month
-
Day
Year
Date
Secondary Insurance:
Primary Insured Party Name:
DOB:
-
Month
-
Day
Year
Date
Relationship to Patient:
Policy #:
Group #:
Effective Date:
-
Month
-
Day
Year
Date
Expiration Date:
-
Month
-
Day
Year
Date
Insurance Card Images
*
Browse Files
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CURRENT PROVIDERS
Therapist:
Psychiatrist:
PCP:
Case Manager:
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PRESENTING PROBLEM(S)
Briefly describe the patient's current challenges and what has been most helpful so far:
*
What are the goals for treatment?
*
Does the patient have access to a computer or tablet with a webcam and reliable internet connection?
*
Yes
No
Does the patient have access to a private space for the duration of daily programming (3-5 consecutive hours)?
*
Yes
No
Is the patient currently on an Inpatient unit?
*
Yes
No
If yes, what is the discharge date?
-
Month
-
Day
Year
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 Ideation
Self Injurious Behavior
Homicidal Ideation
Violence History
None
Any other CURRENT symptoms/challenges that are important for us to know?
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SUBSTANCE USE
Are any of the below currently being used?
*
Tobacco
Opiods/Opiates
Alcohol
Cannabis
Nicotine
None
Other
REFERRAL SUBMITTED BY
Person submitting referral:
*
Relationship to patient
Email address:
*
example@example.com
Telephone #:
*
Format: (000) 000-0000.
Date:
*
-
Month
-
Day
Year
Date
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