Adult PHP Referral Form - Electronic Version

LINDNER CENTER OF HOPE
Referral For Services
Mindful Transitions Adult Partial Hospitalization Program
To be completed by a treating medical provider ONLY.
Please contact us if you have any questions. PHP Office Phone 513-536-0682
Email: MindfulPHP@LindnerCenter.org
PHP Fax 513-536-0689
Demographic Information
Name of patient:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB:

MonthDayYear
Patient preferred phone number:
Format: (000) 000-0000.
Patient email:
example@example.com
Insurance Information (This may be difficult to answer, please provide whatever you can.) Insurance Company
Name:
ID#
Group#
Subscriber Name:
Subscriber DOB:

MonthDayYear
Date
Insurance Company phone number to verify benefits:
Format: (000) 000-0000.

Referral Source Information
Referrer Name:
Agency/Business Name:
Phone Number:
Format: (000) 000-0000.
e-mail address:
example@example.com
How long have you had a clinical relationship with this patient?
Clinical Information
Why does this patient need PHP level of care at this time?
Why is outpatient level of care not sufficient?
Clinical Goals for PHP
Primary Goal:
Secondary Goal:
Current Diagnosis:
Axis I Diagnoses:
Axis II Diagnoses (if applicable):
Previous Inpatient Psychiatric Hospitalizations (specify dates, facilities, and brief reason):
Trauma History (if applicable, please explain):
type n/a if not applicable
Substance Abuse History
Please list problematic substance use (if applicable):
type n/a if not applicable
Longest period of sobriety/when? (if applicable)
type n/a if not applicable
History of inpatient detox and/or rehab/when? (if applicable)
type n/a if not applicable

Current Medication(s) and Dosages (name/dose/dosing instructions)
Current Chronic/ Acute Medical Conditions
Allergies
Current Outpatient Treatment Team
Psychiatrist:
Therapist:
Primary Care:
Other:
Behavioral Issues
Do you feel this patient can stay and sit in a PHP classroom 6 hours per day and learn information without being disruptive to the rest of the class/staff?

Does the patient have any of the following problematic behaviors?

Rows	Active	Past (when?)
Binge eating
Purging
Excessive exercise
Self-harm

Violence history (toward others? If yes, please specify)
Other (please specify)
Is the patient a registered sex offender? (We cannot accept registered sex offenders, so if the answer is Yes; we do not need to know any more details about any sex offender charges.)

Felony convictions or legal history? (please explain)
For planning purposes
Please note that PHP does not allow emotional support animals, only service dogs as required by law. Does this patient have any disabilities for which they may need assistance? (please explain, examples: problems with ambulation, hearing loss, vision loss/blindness, need for service dog).
Does this patient have any disabilities for which they may need assistance? (please explain)
If yes, please explain
Does this patient have a court appointed legal guardian or is such guardianship pending?
If yes, is the PATIENT agreeable to attend and participate in PHP and remain in programming until properly dismissed/discharged?
Is this patient a flight risk or at risk for wandering away and not properly signing out of programming if leaving early?
Will the patient be staying at their local home address (within one-hour of Mason, Ohio while attending PHP?)
If no, where will the patient be staying that is within one hour of Mason, OH and with whom?
* Please note, for safety reasons the patient must agree to provide the address and unit number of where they are staying during the PHP admission and sign a release of information consent granting permission for the PHP program staff to communicate with the person with whom they are staying during the PHP admission.
We appreciate your referral to our Mindful Transitions Adult PHP program. THANK YOU!!

Our PHP clinical staff work Monday-Friday (excluding holidays).

We will let you know if your patient has not been accepted into our PHP program and why. We will attempt to schedule referrals with patients as they are accepted.

If you have a question about your referral, please call us at 513-536-0682.
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LINDNER CENTER OF HOPE

Referral For Services

Mindful Transitions Adult Partial Hospitalization Program

Demographic Information

Insurance Information (This may be difficult to answer, please provide whatever you can.) Insurance Company

Referral Source Information

Clinical Information

Clinical Goals for PHP

Current Diagnosis:

Substance Abuse History

Current Medication(s) and Dosages (name/dose/dosing instructions)

Current Chronic/ Acute Medical Conditions

Current Outpatient Treatment Team

Behavioral Issues

For planning purposes