Follow the steps to complete the TN MH-5253 form online

1. Click the ‘Get Form’ button to obtain the TN MH-5253 form and access it in your browser.
2. Fill in the receiving facility name in the designated space.
3. Enter the referring agency name where indicated.
4. Add the date of referral in the specified format.
5. Provide the date of outpatient evaluation as required.
6. Input the name of the service recipient in the provided field.
7. Enter the service recipient's Social Security number.
8. Fill in the date of birth of the service recipient.
9. Choose the gender of the service recipient and fill in ethnicity, primary language, and docket number.
10. Specify the date(s) of the alleged crime.
11. Indicate the current location or placement of the service recipient.
12. Fill in the county information.
13. Enter the prosecutor's name.
14. Provide the judge's name.
15. Input the name of the defense attorney.
16. List the charge(s), specifying felony and misdemeanor details.
17. Provide a list of all interventions used to prevent the referral, checking applicable options.
18. State the clinical rationale for the referral to the inpatient facility, ensuring not to include 'for forensic evaluation' in the description.
19. If applicable, specify the clinical rationale for referral to the FSP (adult only).
20. List current medications of the service recipient.
21. Detail any current medical concerns.
22. Indicate whether there has been current and/or previous mental health treatment, and specify the facility if applicable.
23. Note information regarding past forensic evaluations, including where and when they occurred.
24. Label the patient identification as required.
25. Finally, review all provided information for accuracy and completeness before submitting.

Complete your TN MH-5253 form online today to ensure a smooth referral process.