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Provider Referral For Behavioral Health Services
Referral To Be Completed By Agency, School, Or Organization
Referral Date:
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Referring Name of Staff Member
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Referring Name of Agency, School, or Organization
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Work Address (Include City & State)
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Zip Code
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Work Email Address (If no, N/A)
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Phone Number
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Best Time To Reach You?
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Aside From Telephone Calls, Please Let Us Know How You Would Like To Receive Information and Notifications From Our Team.
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Email
Text Message
Patient Demographics
Patient's Name
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Patient's Date of Birth (MM-DD-YYYY)
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Patient's Phone Number (If no, N/A)
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Can Voicemails Be Left For Patient?
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No
Yes
Patient's Email Address (If no, N/A)
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Patient's Race:
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African American
Asian
Caucasian
Hispanic
Native American
Unknown/ Prefer Not To Disclose
Other:
Other:
Patient's Gender Identity
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Female
Fluid
Gender Non-Conforming
Genderqueer, Neither Exclusively Male nor Female
Male
Non-Binary
Trans Male/ Trans Masc.
Trans Woman/Trans Fem.
Unknown/ Prefer Not To Disclose
Other:
Other:
Patient's Primary Language
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English
Spanish
Other:
Other:
What Is Patient's Current Living Situation?
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Alone
Assisted Living
Car/Mobile Home
Crisis Residential
Experiencing Homelessness
Rents A Room/ With Roommates
Substance Treatment Facility
Transitional Living
Unknown/ Prefer Not To Disclose
With Friends
With Other Relative(s)
With Same Sex Partner
With Spouse
With Spouse and Children
Other:
Other:
Aside From Telephone Calls, Please Let Us Know How The Patient, Would Like To Receive Information and Notifications From Our Team.
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Email
Text Message
Reason For Referral To Mental Health Services
Please
Check All That Apply.
Medical Necessity = Functional Impairment in Home, School or Community
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Academic Underachievement
Alcohol Abuse
Anger outbursts
Anxious/worries
Behavioral Issues
Bullying/Threatens others
Codependency
Coping Skills
Defiant/oppositional
Delusions
Depressed/sad
Divorce
Eating issues
Grief/loss
Hallucinations
Hyperactive
Impulsive
Inability to focus
Infidelity
Irritable
Panic attacks
Parenting
Peer Relationship
Self-harm
Sexual abuse
Sexualized behaviors
Sleep issues
Substance use
Suicidal or homicidal ideation
Tantrums
Trauma and PTSD
Urgent psychiatric meds
Violent/aggressive
Withdrawn/isolates
Other:
Other:
Is There Any Additional Comments, Challenges, or Concerns That You Believe Would Be Benefical In Sharing About The Patient?
Does The Patient Have Medical Insurance? (Medi-Cal, Kaiser, Anthem, Blue Shield, Etc)
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No
Unknown
Yes
If Yes, What Type Of Medical Insurance Does The Patient Have? (If None, Type N/A)
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-
Level Of Care Services?
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Outpatient (OP) Behavioral Health Services (Office Visit)
Online Counseling Services (Video or Audio)
Is The Patient Aware That A Mental Health Referral Has Been Submiited?
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No
Unknown
Yes
BY CLICKING, I Affirm And Hereby Acknowledge That I Have Completely Read, Understand, And Certify That All The Information And Answers To Questions Are Complete, True, And Correct To The Best Of My Knowledge And Belief. I Understand That Any Misrepresentation, Falsification, Or Omission Of Any Facts In The Provider Referral Application May Warrant Me To Be Contacted For Additional Information. On Behalf Of The Patient, The AMAAD Institute Is Authorized To Collect And Disclose In A Confidential Manner Of Any Information Supplied In This Application To The Parties Namely The Behavioral Health Department, Human Resources Staff, Concerning Department Head Or Above For An Assessment
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