Get Mental Health Referral Form Pdf

Completing the Mental Health Referral Form Pdf is an essential step for individuals seeking behavioral health care coordination for children and youth. This guide provides detailed, step-by-step instructions to help users fill out the form accurately and efficiently online.

Follow the steps to successfully complete the referral form.

1. Click ‘Get Form’ button to obtain the form and access it within your preferred online editor.
2. Fill in the demographic information section by providing the youth's name, phone numbers, gender, date of birth, address, city, zip code, state, and MA number as requested.
3. Complete the parent or legal guardian information. If applicable, include a court order and provide contact details like address, phone number, and email.
4. Indicate the youth's ethnicity/race by checking the appropriate boxes, and specify the primary language. If interpreter services are necessary, mark 'Yes' or 'No' as required.
5. Document the living situation of the youth, specifically whether they currently reside in a group home or similar facility.
6. Provide information regarding the behavioral health diagnosis. Include who diagnosed it, any medical diagnoses impacting the behavioral health diagnosis, and corresponding DSM 5/ICD codes.
7. Detail the current medications the youth is taking, including names and dosages. Mark ‘None’ if applicable.
8. Explain the reason for referral by providing a brief description of why the youth is being referred for services.
9. Review and complete the release of information section, ensuring a signature from the parent or legal guardian is obtained.
10. Finally, select the level of care intended for the youth by checking the corresponding box. Answer any required questions and provide additional documentation if needed.
11. Save your changes, download the completed form, print it, or share it according to your needs.

Begin filling out the Mental Health Referral Form Pdf online today for effective care coordination.