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MENTAL HEALTH REFERRAL FORM www.albertsons.com/specialtycarePhone: 877.466.8028Fax: 877.466.8040 Patient Name: DOB: Sex:Patient InformationPhone: Cell Phone: Email Address: Address: City: State: Zip:
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How to fill out mental health referral form
How to fill out mental health referral form
01
To fill out a mental health referral form, follow these steps:
02
Start by entering your personal information such as your name, date of birth, and contact details.
03
Provide details about your current mental health condition, including any symptoms you are experiencing and when they started.
04
Describe your previous mental health history, including any diagnoses you have received and treatments you have undergone.
05
If applicable, mention any medications you are currently taking for your mental health condition.
06
Include information about any other healthcare professionals you are currently seeing for your mental health.
07
Provide any additional information or concerns you may have related to your mental health that you feel is important for the referral.
08
Lastly, review the form to ensure all information is accurate and complete before submitting it.
Who needs mental health referral form?
01
The mental health referral form is typically needed by individuals who require specialized mental health services or treatments. This form is usually used by individuals seeking referrals from their primary care physicians or therapists to see a specialist, such as a psychiatrist or psychologist. It is also commonly used by individuals seeking mental health support through employee assistance programs, community health centers, or insurance providers. Overall, anyone who needs to access mental health services beyond general counseling may be required to fill out a mental health referral form.
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What is mental health referral form?
The mental health referral form is a document used to refer individuals to mental health services and resources.
Who is required to file mental health referral form?
Healthcare providers, social workers, school counselors, or anyone concerned about an individual's mental health may be required to file a mental health referral form.
How to fill out mental health referral form?
To fill out a mental health referral form, one must provide the individual's personal information, reason for referral, any relevant medical history, and contact information for additional support.
What is the purpose of mental health referral form?
The purpose of the mental health referral form is to connect individuals in need with appropriate mental health services and support.
What information must be reported on mental health referral form?
The information reported on a mental health referral form typically includes the individual's name, age, address, reason for referral, any known mental health conditions, and contact information.
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