Referral Form - Cedar Hills
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1
2Referral Form
Please complete this form, attach additional clinical information, as needed and fax to 503.535.7370.
Referring Professional Information
Time________________ Date_____/______/_____
Referring Professional _____________________________ ____Agency __________________________________City ______________________ State______
Work Phone__________________________ Cell Phone _____________________Fax #____________________ Pager _____________________
Patient Information
Patient Last Name _____________________________________ Patient First Name____________________________________ Patient (Middle,Sfx). _________
Patient Birth Date_____________________ Age____________________ SSN #. ______________________________ Sex ______Marital Status______________
Patient Address
_____________________________________________________________________________________________________________________
Patient City/St/Zip __________________________________________________ Cell/Home Phone _____________________ Work Phone___________________
Family/Guardian Full Name _________________________________________ROI Y N Cell/Home Phone ___________________Work Phone___________
Level of Care & Treatment Program Recommendation
Inpatient Hospitalization
Mental Health
Women’s Program
Partial Hospitalization/ Day Treatment
Detox
Behavioral Pain Management Program
Intensive Outpatient Program
Co-occurring MH/SA
Impaired Professionals Program (IOP Only)
Unsure
Substance Abuse Inpatient Rehab
Military Program
Clinical Situation *Please provide any additional collateral information
Presenting Problem _____________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________Commitment Status VOL INVOL
Diagnosis _______________________________________________________________________________________________________________________________
HIGH RISK FACTORS:
SUICIDAL: YES NO
Plan_____________________________________________________ Attempt_____________________________________________
HOMICIDAL: : YES NO
Plan__________________________________________________ Attempt_____________________________________________
PSYCHOSIS: : YES NO
Describe____________________________________________________________________________________________________
CHEMICAL DEPENDENCY: YES NO
Substances: _________________________________________________________________________________________________ Last Use____________________
Substances: _________________________________________________________________________________________________ Last Use____________________
Substances: _________________________________________________________________________________________________ Last Use____________________
SELF HARM: YES NO
Describe___________________________________________________________________________________________________
AGGRESSION: : YES NO
Explain__________________________________________________________________________________________________
Previous Treatment __________________________________________________________Current Treatment: YES NO Where ______________________
__________________________________________________________________________________________________________________________
ALLERGIES __________________________________________________________________________________________________________________________
MEDICATIONS ________________________________________________________________________________________________________________________
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Parent category: Medical