Behavioral Health Internal Referral Form
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indicates a required field
Patient Name
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First Name
Last Name
Street Address
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Street Address
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Street Address Line 2
City
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State
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Zip code
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Patient's Contact Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Language
*
Does your patient have Medicare and/or Medicaid? Select all that apply.
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Medicare
Medicaid
Medicare and Medicaid
Commercial / Private Insurance
Uninsured
Please indicate any current safety concerns for this patient. (Select all that apply.)
None known
Safety status unknown / unable to assess
Mild distress, with no thoughts of harm
Thoughts of self-harm, with no plan or intent
Thoughts of harm to others, with no plan or intent
Active plan or intent to harm self or others
What insurance does your patient have currently?
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Medicare
Medicaid
Medicare and Medicaid
Commercial / Private Insurance
Uninsured
Insurance Provider
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(e.g., VNS Health, Healthfirst)
Medicare ID
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Medicaid ID
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HCHB Medical Record Number
*
If no HCHB Record Number, enter N/A.
Guiding Care V Number
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If no Guiding Care Number, enter N/A.
Name of Referrer
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First Name
Last Name
Name of Referrer's Program
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(e.g., Hospice)
Referrer Email
*
example@example.com
Reason for Referral
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Session ID
Submit
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