Get Referral Intake Form - Mission Health

Completing the Referral Intake Form for Mission Health is an important step in securing the necessary support for individuals seeking assistance. This guide will provide you with clear instructions on how to efficiently and accurately fill out the form online.

Follow the steps to complete your referral successfully.

1. Click 'Get Form' button to obtain the form and open it in your document editor.
2. Begin by filling in the health care provider's information making the referral. Include their name, telephone number, fax number, and address.
3. Provide the patient's full name, date of birth, and age in the appropriate fields. Make sure all information is accurate.
4. Enter the patient's mailing address, including street, town, and zip code.
5. List the names of the parents or guardians. Fill in 'Mother,' 'Father,' and any other relative or guardian as necessary.
6. Input the home and work phone numbers for the parents or guardians, as well as any cell phone numbers for each parent.
7. Indicate whether an interpreter is needed by selecting 'Yes' or 'No.'
8. Provide the insurance information if applicable, including the insurance provider and ID number.
9. Complete the section designated for the referring provider. Write down the referring concern, any other providers involved, established or suspected diagnosis, previous psychoactive medications, and current medications.
10. Answer questions regarding previous psychiatric evaluations, hospitalizations, history of abuse, legal troubles, and school expulsions, selecting 'Yes' or 'No' as applicable.
11. Evaluate the urgency of the referral and circle the appropriate response: 'Routine,' 'Semi-Urgent,' or 'Urgent.' Provide a brief explanation for urgent referrals.
12. In the office use section, leave space for date, signature, and comments where the staff can complete the necessary follow-up details.
13. After ensuring all fields are filled accurately, save the form. You can download, print, or share it as needed.

Complete your Referral Intake Form online today for timely assistance.