Psychiatric Services / Medication Management Referral Form
Please share your details and information about the client you'd like to refer. This form is fully HIPAA-compliant, keeping all Protected Health Information (PHI) safe and secure. Thank you!
Referred Client Information
Client Full Name
*
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client Email Address
example@example.com
Halfway House
*
DOC Number
Medicaid ID Number
Case Manager
*
Case Manager Email
*
example@example.com
Bridge Prescription Request Form
If the client is currently out of a prescribed psychiatric medication, please list the medication(s) below. Balanced Mental Wellness will review the request and, if appropriate, send a bridge prescription to the client's preferred pharmacy. Please be aware that bridge prescriptions cover only enough supply to last until the intake appointment, are limited to one request per client, available exclusively to correctional clients, and subject to approval by the Medical Director.
Preferred Pharmacy:
*
Please note: We generally do not provide medical medications unless specific circumstances arise. We are happy to assist with referrals to primary care physicians for non-psychiatric medication needs.
Only Medications a Bridge Prescription is Needed For:
Rows
Medication Name:
(Spelling errors OK)
Example: Suboxone
Medication Dose:
(mg, mL, gm, etc)
Example: 8-2 mg
Frequency:
(how often)
Example: Once Daily
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Additional Notes or Relevant Information
Please upload any files you would like us to have
Example: Release of Information, Medical Records, Treatment Referral Packet, etc.
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit Referral
Should be Empty: