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346.646.4892

Provider Referral Form

Complete questions below to request an IOP intake assessment. Admission is determined after clinical assessment and review of program fit. Use a secure submission method arranged with the intake team.

Patient Information

Patient First Name*

Patient Last Name*

Date of Birth*

Month

Day

Year

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Patient Phone*

Preferred Language

Voicemail Acceptable?

Yes

No

Patient Email*

Emergency Contact Name*

Emergency Contact Phone*

Relationship*

Referring Provider

Referring Provider Name *

Organization*

Address*

Phone*

Secure Fax*

Secure Email*

Referral Source*

Referral Contact if Different

Phone*

Reason For Referral *

Coverage and Payment

Payment*

Primary Insurer and Plan

Member ID

Group Number

Subscriber Name

Date of Birth

Month

Day

Year

Relationship to Patient

Secondary Coverage If Applicable

Clinical Information

Primary Diagnosis and ICD 10 code (if known)*

Additional Diagnoses

Symptoms, Functional Impairment, and Treatment Goals*

Current Medications and Prescriber

Medications Upload

Relevant Medical Conditions, Allergies, and Accessibility Needs

Current Therapist

Phone

Email

Current Psychiatric Provider

Phone

Email

Recent Hospitalization or Emergency Evaluation*

Yes

No

Unknown

Facility, Dates, Discharge Date, and Follow Up Needs

Safety & Level of Care Information

Document known concerns and the most recent assessment. Attach details when needed.

Suicidal Thoughts or Behaviors*

No Known Concern

Concern Present

Uknown

Suicidal Thoughts or Behaviors File Upload

Risk of Harm to Others*

No Known Concern

Concern Present

Unknown

Risk of Harm to Others File upload

Psychosis, Mania, Substance Abuse, or Withdrawal Concerns

Assessment Date, Current Safety Concerns, and Actions Taken

THIS FORM IS NOT MONITORED FOR EMERGENCIES. For an immediate emergency, call 911 or direct the patient to the nearest emergency department.

Vitrual Participation and Care Coordination

Patient Location During Treatment*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Access to Private Space, Internet, and Video Capable Device*

Participation Barriers or Scheduling Needs

Patient Informed of Referral*

Patient Agrees to Intake Contact*

Release of Information for Coordination*

Attached

Pending

Not Applicable

Release of Information for Coordination File upload

Requested Updates

Intake Outcome

Progress

Discharge Plan

Attachments and Provider Attestation

Attachments

Assessment

Medication List

Discharge Summary

Safety Plan

Insurance Card

Release of Information

Other

Attachments and Provider Attestation File Upload

To the best of my knowledge, the referral information is accurate. I have provided Provider relevant records through a secure channel and follow applicable consent and disclosure requirements.

Provider Signature*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

346.646.4892

info@HambrickCenter.com

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