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How to fill out the Regional Assessment And Referral Form online
Filling out the Regional Assessment And Referral Form online is a straightforward process that allows users to provide essential information for referral to various inpatient and outpatient services. This guide will walk you through each section of the form, ensuring you understand what information is required.
Follow the steps to complete the form accurately and efficiently.
- Press the ‘Get Form’ button to access the form and open it in your preferred editor.
- Begin by entering the referral information. Fill out the name of the staff taking the referral, the referral agency, and their phone number. Indicate the outpatient psychiatrist and whether a follow-up appointment has been scheduled, specifying the details if applicable.
- Next, provide the history and demographic information. Input the individual's name, maiden name (if applicable), date of birth, age, and social security number. For gender, select from the options provided, and answer whether the person is pregnant.
- Continue with contact details including phone number, county of residence, full address, and ethnicity. Choose the primary language and indicate English proficiency. Then, select marital status and living arrangement.
- Fill in educational level and provide details about the guardian and emergency contact, including their phone numbers and relationship to the patient.
- Complete the insurance information, detailing relevant Medicaid and Medicare numbers, along with the insured’s name, date of birth, and employer. Be sure to fax the front and back of the insurance card as required.
- In the clinical information section, provide an overview of risk factors such as suicidality, self-injurious behaviors, or violence, selecting the appropriate response options.
- For substance use, list current usage, including frequency and duration, and answer associated questions regarding detox needs and history.
- Fill in medical and legal history, including current/pending legal charges and court dates. Provide any necessary medical background, including history of traumatic brain injury or mental health conditions.
- In the mental status examination section, articulate observations regarding the individual's appearance, attitude, mood, cognition, and thought processes.
- Finally, review the entire form for completeness and accuracy. Once finished, save your changes, download, print the form, or share it as needed.
Begin completing your Regional Assessment And Referral Form online today to ensure a smooth referral process.
The San Diego Regional Center serves individuals with developmental disabilities and their families. If you or someone you know needs support, it’s important to inquire about your eligibility. Submitting the Regional Assessment And Referral Form will help streamline this process, allowing you to explore the available resources tailored to your needs.
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