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Los Angeles Unified School District
STUDENT HEALTH AND HUMAN SERVICESSCHOOL MENTAL HEALTH CLINIC REFERRALReferral Cover Sheet
Date:
Name of Person Completing Referral:
Are you a (Check one):Parent/Legal
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How to fill out clinical forms-referrals
How to fill out clinical forms-referrals
01
Obtain the necessary clinical forms-referrals from the healthcare provider or facility where the patient is being referred.
02
Read and understand the instructions provided on the forms carefully before filling them out.
03
Fill out the patient's personal information accurately, including their name, date of birth, address, and contact information.
04
Provide details of the referral reason and any relevant medical history or conditions that may be important for the healthcare provider to know.
05
Make sure to sign and date the forms as required before submitting them to the designated recipient.
Who needs clinical forms-referrals?
01
Patients who are being referred from one healthcare provider to another.
02
Healthcare providers who are referring a patient to another specialist or facility for further evaluation or treatment.
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What is clinical forms-referrals?
Clinical forms-referrals are documents used to refer a patient from one healthcare provider to another for specialized care or services.
Who is required to file clinical forms-referrals?
Healthcare providers such as physicians, nurses, and therapists are required to file clinical forms-referrals when referring a patient for specialized care.
How to fill out clinical forms-referrals?
Clinical forms-referrals should be filled out with the patient's information, reason for referral, and any relevant medical history. It should also include the healthcare provider's information and signature.
What is the purpose of clinical forms-referrals?
The purpose of clinical forms-referrals is to ensure smooth and coordinated care for the patient by providing necessary information to the receiving healthcare provider.
What information must be reported on clinical forms-referrals?
Clinical forms-referrals must include the patient's name, date of birth, contact information, reason for referral, relevant medical history, and the referring healthcare provider's information.
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