Referral Form - The Military Program
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1Referral Form
The Military Program – Cedar Hills Hospital
Please complete and send with attached clinical information to or fax to (503) 345-3415
Patient Name:____________________________ M-
F-
SSN:______________ DOB:__________ Pt Cell:_______________
Active Duty Sponsor:___________________________ M-
F-
SSN:______________ DOB:_________ Cell:______________
: ____________________________________________________________________________
Diagnosis
(Primary / Secondary)
Medications: _________________________________________________________________________________________________
Medical Concerns: ____________________________________________________________________________________________
Pain Management Issues: ______________________________________________________________________________________
Substance Abuse:
-NA Date of Last Use: ___________________ Primary Substances: __________________________________________
______________________________________________________________________________________________
High Risk Alerts:
-Suicide
-Self Injury
-Aggression
-Fall
-Medical
-Sexual Aggression
-Sexual Victimization
-Elopement
Details:
___________________________________________________________________________________________________________
Currently Hospitalized?
-NO
-YES; Contact Info:_______________________________________________________________________
Patient to Deploy?
UCMJ Actions?
Recommended Length of Stay:
-NO
-YES
-NO
-YES
___________________
Military Occupation: _____________________________________ Current Occupation: ___________________________________
Other Information: ____________________________________________________________________________________________
Duty Station: _________________________________________________________________________________________________
Unit Commander Rank/ Name: __________________________________________ Unit: ___________________________________
Non-DSN Phone: __________________ Email: ____________________________________ Emergency #: ____________________
Will patient be discharged to the same Unit / Installation?
-YES
-NO; describe alternate plan: ________________________________
_________________________________________________________________________________________________________________
Fort/Base Behavioral Health or Substance Abuse Department: _______________________________________________________
Primary Clinical Contact: ____________________________________________ Dept: _____________________________________
Non-DSN Phone: ________________________________ Email: _____________________________________________________
Fort / Base Substance Abuse Program: ________________________________________ Dept: _____________________________
Non-DSN Phone: ________________________________ Email: ______________________________________________________
Service Substance Abuse Program Referrant: ___________________________________ Dept: _____________________________
Non-DSN Phone: ________________________________ Email: ______________________________________________________
PCM Contact: ______________________________________________________________ Dept: ____________________________
Non-DSN Phone: ________________________________ Email: ______________________________________________________
Referring Professional: ________________________________________________________________________________________
Installation: ________________________________________________________ Dept: ____________________________________
Non-DSN Phone: __________________ Email: _____________________________________ Emergency #: ___________________
A portion of the medical record will be provided at the time of discharge. If not initially included, a typewritten Discharge Summary will be
faxed within three business days of the discharge. Please identify the individual to receive the Discharge Summary.
Name: __________________________________ Phone: __________________________ Fax: ____________________________
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