Adult Outpatient Mental Health Services Coordinated Intake Referral Form (Page 2 of 2) in pdf

ADULT OUTPATIENT MENTAL HEALTH SERVICES COORDINATED INTAKE REFERRAL FORM

Patient Name:

Reason for referral request and presenting issues:

Brief Description

_____________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________

Diagnostic clarification/Treatment Recommendations

Group Therapy



*Please note patients are accepted for initial psychiatric assessment on a consultative basis and a consult will be

provided for all patients prior to any group linkage unless there is a psychiatrist already involved in care.

Psychiatry follow up and limited individual therapy may be available, however, this is based on clinical indication, not preference.

Working Diagnosis _____________________________________________________________________________________

Past Mental Health Hospitalizations:

________________________________________________________________________________________________________________________________________________

Psychosocial / Other Issues:

 Marital/Custody

 Sexual Abuse

 Emotional Abuse

 Financial Issues

 Housing

 Work/School Problems

 Anger/Temper

 Grief/Traumatic Loss

*Please note requests for third party assessments are unavailable.

Relevant Medical History / Developmental History:

(i.e., endocrine/developmental delay)

________________________________________________________________________________________________________________________________________________

All Current Medications:

*PLEASE PROVIDE A COMPLETE MED LIST BELOW OR AS AN ATTACHMENT

________________________________________________________________________________________________________________________________________________

Allergies:

(Specify)

________________________________________________________________________________________________________________________________________________

PHYSICIAN / NURSE PRACTITIONER

SIGNATURE REQUIRED:

________________________________________________________________________________________________________________

Date

(YYYY/MM/DD)

__________________________________

NS5497 (Rev. 2015/11/26) Page 2 of 2

Adult Outpatient Mental Health Services Coordinated Intake Referral Form Page 2