Behavioral Health Referral Form
Information about Agency/Person Completing Referral
Date
-
Month
-
Day
Year
Date
Name of Individual Making Referral
First Name
Last Name
Agency Making Referral
Agency Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Individual Information
Recommended Triage Priority
Emergent (within 24 hrs)
Urgent (within 48 hrs)
Routine (within 7 days)
Name of Individual being Referred for Services
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Last 4 of SSN
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Individual aware of this Referral?
Yes
No
Currently Receiving Mental Health Services
No
Yes (please enter agency below)
Current Mental Health Provider
Mental Health Agency currently providing services
Parent/Guardian Name (if individual is a minor)
First Name
Last Name
Relationship
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Insurance Information:
Uninsured
Private/Commercial
Medicaid
Medicare
MCO- Trillium, Vaya, Alliance
Other
Insurance ID#
Services Information
Type of Services Needed
Adult
Child/Youth
Community Based Services
Residential (Group Home)
Residential Substance Use Treatment
School Based Therapy
Primary Care/Chronic Disease Management
Community Based Service Requested:
IIH (Intensive In-Home)
MST (Multi-systemic Therapy)
ACTT (Assertive Community Treatment)
CST (Community Support Team)
SACOT (Substance Abuse Comprehensive Outpatient Treatment)
SAIOP (Substance Abuse Intensive Outpatient Program)
PSS (Peer Support Services)
PSR (Psychosocial Rehab)
Medication Management
Other
Residential Service requested:
Youth Residential Group Home (Level 2)
Adult Psychiatric Residential Group Home
Social Setting Detox (ASAM 3.2 WM)
Adult Substance Use Residential (ASAM 3.1)
Other
Individual Gender
Male
Female
Other
Individual Primary Language
English
Spanish
Other
Reason for Referral (Please provide specific information of precipitating events that led to this referral.)
Current Medications
Primary Care Physician Information
Physician Name, Address or Phone
Select all applicable challenges below for the Individual referred (check all that apply)
Anger
Anxiety
Community Linkage of Services
Daily living skills
Depression
Grief
Housing
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Medication Education
Phobia/s
PRTF/Hospital Discharge
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy
Whole Health/Wellness
Suicidal/Homicidal thoughts/attempts
Other
Attach additional documents here (i.e., CCA, PCP, hospital d/c summary, etc):
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: