Pm Form 3.3.1 - Adhs/dbhs Referral For Behavioral Health Services
Download a blank fillable Pm Form 3.3.1 - Adhs/dbhs Referral For Behavioral Health Services in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Pm Form 3.3.1 - Adhs/dbhs Referral For Behavioral Health Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Submit by Email
Print Form
PM FORM 3.3.1
ADHS/DBHS REFERRAL FOR BEHAVIORAL HEALTH SERVICES
I. Information on Person Making Referral
Today’s Date and Time ________________________________
Name and Title ________________________________________________________________________________________________
Affiliated Agency ________________________________________ Phone ______________________ Fax ______________________
One Time Consultation
Ongoing Behavioral Health Services
Type of Service Requested:
II. Information on Person Being Referred for Services
Name ________________________________________________
Date of Birth ________________________
SS# ____________________
Gender
F
M
Primary Language ___________________________
Address _____________________________________________________________________________________________
City __________________________ State _____ Zip _______ Home Phone _________________ Cell Phone _________________
Current location (if not above address) _______________________________________________________________________________
Parent/Legal Guardian (if applicable) _______________________________________________ Phone ___________________________
Identify individual(s) that the member, parent or guardian may wish to be invited to initial appointment with person
(include phone)
_______________________________________________________________________________________________
Person/Parent/Guardian is aware of referral:
No
Yes
Cultural and language considerations
No
Yes
Is an interpreter needed:
No
Yes
If yes, specify language/need
_________________________
Special Needs:
Mobility Assistance
No
Yes, identify assistance needed _________________________________
Visual Impairment Assistance
No
Yes, identify assistance needed _________________________________
Hearing Impairment Assistance
No
Yes, identify assistance needed _________________________________
Developmental or Cognitive Impairment
No
Yes, identify assistance needed __________________________
Payment Source:
AHCCCS ID # _____________________
Health Plan Name _______________________________
Self pay
Private insurance
Medicare
Other ___________________________
PCP _____________________________________________ Phone ____________________ Fax _________________________
Check any of the following which pertain to the person being referred:
Shows evidence of suicidal or homicidal thought or behaviors
Identified need for psychotropic medications
Pregnant Woman
Is currently hospitalized
Was recently discharged from an inpatient setting
Has immediate medical needs
Other potential risk factors, e.g., dehydrated, malnourished, homeless
Reason for Referral, including an explanation of any items checked above _____________________________________________
_________________________________________________________________________________________________________
If the person is taking medications to treat a behavioral health condition, does she/he have an adequate supply for the next 30 days?
Yes
No If no, when will she/he exhaust the current supply of medications? ______________________________________
Last revision: 08/21/2009
1
Effective date: 07/01/2009
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical