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Eastside Psychological Services, Inc. REFERRAL FORM FOR THERAPY SERVICES (323) 8901167 FAX Reason for Referral: Sexual Abuse Physical Abuse Domestic Violence Child Endangerment (Drug Abuse, Weapons,

How to fill out eastside referral form

How to fill out eastside referral form:

1. Start by gathering all the necessary information required to fill out the form, such as the patient's personal details, medical history, and current condition.
2. Enter the patient's full name, date of birth, and contact information accurately in the designated sections of the form.
3. Provide any relevant insurance information, including the policy number and group number, if applicable.
4. Fill in the referring physician's name, contact information, and any additional details required by the form.
5. Describe the reason for the referral in detail, including any symptoms, diagnoses, or specific services requested.
6. If there are any specific tests or treatments requested, make sure to indicate them clearly on the form.
7. Complete any additional sections or questions as required, such as emergency contact information or special accommodations needed.
8. Review the filled-out form carefully to ensure all information is correct and legible.
9. Sign and date the form to confirm its accuracy and legitimacy.
10. Submit the completed referral form to the appropriate recipient, such as a healthcare provider, specialist, or insurance company.

Who needs eastside referral form:

1. Patients who require specialized medical services from a referral-based healthcare system.
2. Individuals seeking a second opinion from a specialist.
3. Patients whose insurance coverage requires a referral for certain medical services.
4. Individuals seeking specific tests, procedures, or treatments that require a referral from their primary care physician.
5. Patients who are transferring their care to a new healthcare provider or specialist.

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What is eastside referral form?

Eastside referral form is a document used to refer clients or patients to services or resources located on the east side of a specific area.

Who is required to file eastside referral form?

Healthcare providers, social workers, counselors, or any individual involved in providing services to clients who may benefit from resources on the east side are required to file the eastside referral form.

How to fill out eastside referral form?

The eastside referral form can be filled out by entering the client's information, the reason for the referral, and specifying the services needed on the east side. The form should then be submitted to the appropriate department or organization.

What is the purpose of eastside referral form?

The purpose of the eastside referral form is to connect clients with services available on the east side, ensuring they receive the support and resources they need for their well-being.

What information must be reported on eastside referral form?

The eastside referral form must include the client's name, contact information, reason for referral, preferred services on the east side, and any relevant details about the client's situation.