Referral to Behavioral Health Services Form

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Referral Source (Category)

Agency Name *

Referring Staff Name *

First

Last

Phone Number *

Fax Number

Email *

Patient Information

Patient Information *

First

Middle

Last

Date of Birth *

Alias / Maiden Name

Sex

Last Known Address

Address Line 1

Address Line 2

City

State

Zip Code

Social Security Number

Current Living Situation *

Own Home
Friend’s / Relative’s Home
Homeless
Incarcerated

If Incarcerated, Please list name of facility

Anticipated Release Date

Reason for incarceration

Does the patient have an open Children Services case?

If yes, please explain:

Reason for Referral:

Is there a court order for SUD treatment?

Explain:

Services Requested:

Comprehensive Assessment
Medication Assisted Treatment (MAT)
Perinatal
Psychiatry
SUD Intensive Outpatient
SUD Outpatient
SUD Residential
Detox (coming soon)

If requesting SUD residential services

Has the patient been in SUD Residential treatment within the past 12 months?

Explain:

Insurance Information

/ please was

Does the patient have:

Medicaid
Private Insurance
No Insurance
Other

If Other, please explain:

Insurance Company

Insurance / Medicaid Number

Has the patient applied for Medicaid in the past 30 days?

If yes, please explain:

If incarcerated, is the patient enrolled in the Medicaid Pre-Release Enrollment Program?

If yes, please explain:

Patient Health

Does the patient have a mental health diagnosis?

If yes, please explain:

Is the patient receiving mental health services?

If yes, please list Agency / Provider:

Does the patient have any health concerns that may impact treatment?

If yes, please explain:

Is the patient pregnant?

If yes, what is the Due Date?

Is the patient receiving prenatal care?

If yes, please elaborate (Agency, etc):

Prescribed Medication

Is the patient compliant with Prescriber order?

Prescriber

Additional Information

Prescribed Medication

Is the patient compliant with Prescriber order?

Prescriber

Additional Information

Prescribed Medication

Is the patient compliant with Prescriber order?

Prescriber

Additional Information

Substance Use Information

(Alcohol**) Reported Use

Positive Drug Screen Result

Date of Last Use

Known Frequency

Daily
1 – 3 times a week
1 – 3 times a month

(Benzodiazepines**) Reported Use

Positive Drug Screen Result

Date of Last Use

Known Frequency

Daily
1 – 3 times a week
1 – 3 times a month

(Cannabis / Marijuana) Reported Use

Positive Drug Screen Result

Date of Last Use

Known Frequency

Daily
1 – 3 times a week
1 – 3 times a month

(Crack / Cocaine) Reported Use

Positive Drug Screen Result

Date of Last Use

Known Frequency

Daily
1 – 3 times a week
1 – 3 times a month

(Hallucinogens) Reported Use

Positive Drug Screen Result

Date of Last Use

Known Frequency

Daily
1 – 3 times a week
1 – 3 times a month

(Heroin) Reported Use

Positive Drug Screen Result

Date of Last Use

Known Frequency

Daily
1 – 3 times a week
1 – 3 times a month

(Inhalants) Reported Use

Positive Drug Screen Result

Date of Last Use

Known Frequency

Daily
1 – 3 times a week
1 – 3 times a month

(Methadone) Reported Use

Positive Drug Screen Result

Date of Last Use

Known Frequency

Daily
1 – 3 times a week
1 – 3 times a month

(Suboxone / Subutex) Reported Use

Positive Drug Screen Result

Date of Last Use

Known Frequency

Daily
1 – 3 times a week
1 – 3 times a month

(Prescription Opiates) Reported Use

Positive Drug Screen Result

Date of Last Use

Known Frequency

Daily
1 – 3 times a week
1 – 3 times a month

(Other Sedative / Tranquilizers) Reported Use

Positive Drug Screen Result

Date of Last Use

Known Frequency

Daily
1 – 3 times a week
1 – 3 times a month

Evaluation requirement

How long was the patient’s last period of voluntary abstinence from their preferred substance?

Has the patient experienced withdrawal symptoms during past attempts to stop use?

If yes, please explain:

Has patient ever experienced an overdose?

If yes, please explain:

Has patient ever been administered Narcan?

If yes, please list dates:

Is patient’s living environment supportive of recovery?

If no, please explain:

Does patient have a recovery support system?

If no, please explain:

Does patient have the skills to maintain recovery?

If no, please explain:

Is patient motivated to seek treatment?

If no, please explain:

Does the patient have any of the following legal charges or convictions? If yes, please email us supporting documentation.

Arson
Assault
Child Endangering
Domestic Violence
Drug Charges
DUI / OVI
Homicide / Manslaughter
Major Driving Violations

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Referral to Behavioral Health Services Form

Patient Information

Insurance Information

Patient Health

Substance Use Information