EPHP Referral Form

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EPHP Referral Form

EPHP Referral Form

Please fill out entire referrals form.

Client Name:
First & Last
Phone:
Email:
Transportation:
Demographic Information
Referral Date:
MM slash DD slash YYYY
Date of Birth:
MM slash DD slash YYYY
Social Security Number:
Address:
Street Address Address Line 2 City State ZIP Code
Marital Status:
Primary Language:
Current Living Situation:
Legal Information
Does Patient have Legal Guardian?
Guardian Name:
First Last
Guardian Phone:
Emergency Contact
Emergency Contact Name:
First Last
Emergency Contact Phone:
Emergency Contact Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Information
Primary Insurance:
Policy Number:
Subscriber Name:
First Last
Subscriber Date of Birth:
MM slash DD slash YYYY
Secondary Insurance:
Policy Number:
Subscriber Name:
First Last
Subscriber Date of Birth:
MM slash DD slash YYYY
Clinical Information
Presenting Problem(s)/Reason for Referral:
Goals for Treatment:
Psychiatric Diagnoses:
Medical Conditions:
Substance Use/Abuse:
Medications:
Suicide Attempts/Self Harm within the past month?
If yes, please explain:
ADA/Accommodations Needed:
Cognitive/Intellectual Disabilities:
Is this a step down from Inpatient?
If referring from Inpatient or Residential, please fax or email H&P, D/C Summary, medication list and any other pertinent information to fax: (508)235-0457 or email [email protected]
Expected Discharge Date
MM slash DD slash YYYY
Referral Information
Name of Referring Agency/Facility:
Contact Person:
First Last
Contact Phone:
Contact Email:
Psychiatric /Med Prescriber:
First Last
Therapist:
First Last
PCP:
First Last
Other:
First Last

EPHP Referral Form

EPHP Referral Form

Demographic Information

Legal Information

Emergency Contact

Insurance Information

Clinical Information

Referral Information