Get Ma Mclean Southeast Adult Partial Hospital Program Referral Form 2021

Filling out the MA McLean SouthEast Adult Partial Hospital Program Referral Form online can streamline the referral process for individuals seeking support for mood disorders. This guide offers clear instructions to assist users in completing the form accurately and efficiently.

Follow the steps to complete the referral form online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide the date of referral in the designated field. This helps track when the referral was initiated.
3. Enter the patient's name and date of birth. Accurate identification is essential for processing.
4. Fill in the patient's address, city/state, and zip code to confirm their location.
5. Complete the contact information, including home phone, cell phone, and email.
6. Specify the patient’s occupation and current living situation to provide context for their care needs.
7. List of transportation options to attend the Partial Hospital Program.
8. Indicate who referred the patient and provide their contact number for follow-up.
9. Fill in the insurance company details, including name and contact number for benefits verification.
10. Provide the patient's insurance ID number and group number, along with the subscriber's information.
11. Describe why the patient requires a partial hospital level of care, outlining any relevant details.
12. Outline the goals for referring the patient to the MSE Partial Hospital Program.
13. List any psychiatric diagnoses relevant to the patient’s treatment.
14. Detail any previous inpatient or detox hospitalizations, specifying dates, facilities, and reasons.
15. Complete the substance use history section, including the type of substance, amount, and frequency.
16. Indicate the duration of use and date of last use for substances listed.
17. Report the longest period of sobriety, specifying when this occurred.
18. Mark whether there is a history of an eating disorder and provide current height and weight if applicable.
19. Indicate any history of suicide attempts and self-injurious behavior, including details when applicable.
20. Document the current safety status regarding suicidal or homicidal thoughts.
21. List current medications along with dosages to inform the treatment team.
22. Report the last blood level results for medications if relevant.
23. Include any medical conditions and known allergies in the appropriate sections.
24. Complete current outpatient treatment team details, ensuring all relevant contacts are included.
25. Indicate any legal issues or court dates, providing explanations as needed.
26. Sign the form with the name of the person filling it out, and print their name for clarity.
27. Ensure to forward copies of required documents such as admission notes and medical tests.
28. After completing the form, save changes. Share, download, or print the document as needed.

Encourage others to complete the required documents online to facilitate timely care.