 
                Get Nc Dmh 1-73-00 2007
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How to fill out the NC DMH 1-73-00 online
The NC DMH 1-73-00 form is essential for making referrals for admission to a state psychiatric hospital or a substance abuse treatment center. This guide will walk you through each section of the form, ensuring that you complete it accurately and comprehensively.
Follow the steps to fill out the form effectively.
- Press the ‘Get Form’ button to obtain the form and open it in your online editor.
- Begin by entering the facility medical record number and the last four digits of the consumer’s Social Security number in the designated fields.
- Indicate the admitting state hospital or ADATC, followed by the date and time of the referral.
- Select the type of referral made, whether by provider, LME, self-referral, or other, and provide the name and contact number of the referral source.
- Fill out consumer/patient personal details including their full name, date of birth, and any other names used.
- Specify the consumer's gender and provide information on the legal guardian or parent's name, relationship to the consumer, and address.
- Document the consumer’s ethnicity and various contact numbers, including home and work.
- Identify the consumer’s county of residence and the type of admission. Mark if the consumer is currently suicidal, homicidal, or voluntary.
- Describe the consumer’s mental status, current withdrawal symptoms, and complete the substance use information if applicable.
- Fill out the ASAM PPC-2R criteria and specify the appropriate level of care required by the consumer.
- Provide details about the consumer’s medical history, psychiatric medications, allergies, and emergency contact information.
- Complete information regarding previous admissions, current medications, compliance history, and any pending legal charges.
- Outline the goals for hospitalization, proposed discharge plans, and any additional social support resources.
- Once all sections are completed, you can save changes, download, print, or share the completed form as needed.
Complete the NC DMH 1-73-00 form online today to ensure an efficient referral process.
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