Get the free MH Intake Referral Form rev 8.01.16 - kidango
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MENTAL HEALTH REFERRAL INTAKE CONFIDENTIAL INFORMATION IMPORTANT REMINDERS: *Referrals MUST be faxed or delivered in person/interoffice mail. Do NOT email. *To inquire on referral status call: Alameda
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How to fill out mh intake referral form
How to fill out mh intake referral form:
01
Start by providing your personal information such as your full name, address, date of birth, and contact details.
02
Next, indicate your current mental health concerns or reasons for seeking assistance. Be as specific as possible to help the intake staff properly assess your needs.
03
If applicable, mention any previous mental health treatments or medications you have received.
04
Specify your preferred method of communication, whether it's in-person, via phone, or through teletherapy.
05
List any insurance information you have, including the name of your insurance provider and your policy number.
06
If you don't have insurance, inquire about any sliding scale or low-income options available.
07
Indicate any accessibility requirements you may have, such as needing wheelchair accessibility or any accommodations for sensory impairments.
08
Briefly describe your preferred language or any language barriers you may face.
09
Lastly, sign and date the form to confirm the accuracy of the information provided.
Who needs mh intake referral form:
01
Individuals who are experiencing mental health challenges and are seeking professional assistance.
02
Those who may have noticed changes in their mental well-being and are looking for guidance, support, or treatment.
03
Individuals who have been recommended or referred by a healthcare professional, such as a primary care provider or therapist, to seek mental health services.
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What is mh intake referral form?
The mh intake referral form is a document used to refer individuals to mental health services.
Who is required to file mh intake referral form?
Healthcare professionals, social workers, or counselors are required to file the mh intake referral form.
How to fill out mh intake referral form?
The mh intake referral form can be filled out by providing information about the individual's mental health issues and contact details.
What is the purpose of mh intake referral form?
The purpose of the mh intake referral form is to connect individuals with the appropriate mental health services and support.
What information must be reported on mh intake referral form?
The mh intake referral form must include the individual's name, contact information, mental health concerns, and any relevant medical history.
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