Get Referral Form Adult Mobile Mental Health Treatment

Filling out the Referral Form for Adult Mobile Mental Health Treatment is an important step in accessing vital mental health services. This guide will provide you with clear and concise instructions to help you complete the form effectively and efficiently.

Follow the steps to complete the online referral form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date of the call in the designated field to document when the referral is being made.
3. Fill in the contact information of the caller, including their name and phone number, ensuring the information is accurate.
4. Indicate the type of referral by selecting one of the options: Self, Agency, Physician, Family/Friend, or Other.
5. In the section for the facility, agency, or physician making the referral, write down the complete name and phone number of the entity.
6. Provide the full name of the person being referred, including their middle initial, their date of birth, insurance information, and social security number.
7. Complete the address field, ensuring to include adequate detail for accurate location identification.
8. Detail the directions to the home of the individual referred, this assists in the mobile treatment process.
9. List the name and phone number of the referring physician, along with the date of the last medical exam.
10. Provide the name and contact number for the psychiatrist, along with the date of their last psychiatric evaluation.
11. Document the diagnosed condition, being as specific as possible to encapsulate the individual's needs.
12. Expand upon the reason for the referral, detailing any pertinent information that would assist in the assessment.
13. Include any additional comments that may be relevant to the referral, which could provide further context.
14. Indicate whether there is a history of substance abuse by checking 'Yes' or 'No' and provide details if applicable.
15. Elaborate on any treatment history with inpatient psychiatric services and drug and alcohol inpatient treatment.
16. Note any history of incarceration or parole status, being honest about the individual's situation.
17. List current medications that the individual is taking to ensure ongoing management of their health.
18. Document other agencies or services the client is receiving to avoid duplication and ensure comprehensive care.
19. Address the history of trauma by indicating 'Yes' or 'No' and provide action taken if applicable.
20. Carefully check the medical necessity criteria for mobile mental health therapy. Mark the applicable criteria that apply.
21. Detail any actions taken regarding the client, including dates of communication and any referrals made.
22. Once all fields are completed, review the entire form for accuracy and completeness.
23. Save your changes, and then download, print, or share the completed form as necessary for submission.

Complete the form online to initiate the referral process for adult mobile mental health treatment.