Directions: with a current biopsychosocial assessment to psych triage at (617) 983-4688 Note: if referring from Partners eCare Facility, only complete * sections Please complete You may call triage (617)983-7060 to confirm receipt and fax this form Patient will be contacted directly to schedule intake *Referral Source *Diagnosis Past Psychiatric History Name: Include ICD-10 codes Agency: Phone: Date of Referral: *Client Information Current Medications Name: Include medication, dose & frequency Current Mental Status MRN: DOB: Address: City: State: Zip: Phone: *Insurance Information History of Presenting Illness Risk Factors Primary Insurance: Why does client need partial level of care now? Suicidal Ideation Policy #: Self Injurious Behavior Secondary Insurance: Homicidal Ideation Policy #: Violent Behavior Trauma *Care Providers Medication Non-Compliance PCP: Describe any checked items: Phone: Fax: Therapist: Phone: Fax: Prescriber: Phone: Fax: Substance Use Information Specific Problem Amount Frequency Last Substance Use Age Use Alcohol Amphetamines/Stimulants Benzodiazepines Cannabis Cocaine/Crack Opiates Tobacco Other
Directions: Please complete and fax this form with a current biopsychosocial assessment to psych triage at (617) 983-4688 Note: if referring from Partners eCare Facility, only complete * sections You may call triage (617)983-7060 to confirm receipt Patient will be contacted directly to schedule intake *Referral Source Name: Agency: Phone: Date of Referral: *Client Information Name: MRN: DOB: Address: City: State: Zip: Phone: *Insurance Information Primary Insurance: Policy #: Secondary Insurance: Policy #: *Care Providers PCP: Phone: Fax: Therapist: Phone: Fax: Prescriber: Phone: Fax: *Diagnosis Include ICD-10 codes Current Medications Include medication, dose & frequency History of Presenting Illness Why does client need partial level of care now? Past Psychiatric History Current Mental Status Risk Factors Suicidal Ideation Self Injurious Behavior Homicidal Ideation Violent Behavior Trauma Medication Non-Compliance Describe any checked items: Substance Use Information Specific Substance Use Problem Age Amount Frequency Last Use Alcohol Amphetamines/Stimulants Benzodiazepines Cannabis Cocaine/Crack Opiates Tobacco Other
partial-hospitalization-program-referral-form.docx