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Professional Referral Form
Referring Party Information
Referrer Name:
*
Referrer’s Agency/Facility:
*
Phone
*
Email
*
Referring Type
Referring Type
*
Hospital SW
DSHS HCS/DDA
MCO Care Liaison
Facility Operator/Personnel
Community Case Manager
Healthcare Provider
Other
Client Information
Client First Name:
*
Client Last Name:
*
Date of Birth:
*
Month
Month
Day
Year
Gender:
*
Language:
*
Ethnicity:
*
Social Security Number:
*
ProviderOne ID:
*
MCO:
*
Choose one
Legal Guardian / Decision Maker (If Applicable)
Name:
Relationship:
Phone:
Email (if available):
Consent for Treatment
Has the client agreed to this referral?
*
Yes
No
If yes: attach completed
ECBH ROI
.
The Following Documentation Must be Submitted with Referral, if applicable:
Medical / Behavioral Health:
Current medication list
Labs
Diagnosis
Medical history
Recent progress notes
Psychosocial assessment
Psychiatric evaluation
Hospital discharge packet
Placement / Support:
HCS / DDA assessments
CARES
Service summary
Support contracts (ECS/SBS/CSS)
Care Team
Hospital Discharge Referrals:
Discharge date
Confirmed placement
Care notes
Safety/elopement risks
Downloadable Documents
LRA Consent Form
Release of Information Form
Please upload any necessary files:
Upload File
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