YOU TURN BEHAVIORAL HEALTH SERVICES LLC - TREATMENT REFERRAL FOR SERVICES
Date of referral
Client Name
Address
Date of Birth
Gender Preference
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Male
Female
Marital Status
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Single
Married
Widowed
Divorced
Separated
Others
Phone
Email
Needed for required documents
Insurance
Policy or MA #
Service Requested
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Psychiatric Evaluation
Individual Therapy
Group Therapy
Family Therapy
Psychiatric Rehab Services
Referral Source
Referral Source Name
Referral Source Phone Number
If patient, write N/A
Current Diagnosis
If unknown, write N/A
Please indicate the current ICD-10 Codes
If unknown, write N/A
Reason for Referral
Frequency of Issue
Very Good
Good
Fair
Poor
Very Poor
Severity
Recent Hospitalizations
Lethality or Safety Issues
Relevant Medical Diagnosis
Current Medication
Name of Medication
Dosage
Frequency
Name of Medication
Dosage
Frequency
Name of Medication
Dosage
Frequency
Name of Medication
Dosage
Frequency
Primary Care Doctor’s Name
Primary Care Doctor’s Phone Number
Accomodations Needed
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Clear choices
TTY
Interpreter
Sign Language
Ambulatory Limitations
None
Is the client currently receiving services with another provider?
Clear choice
Yes
No
If yes, please list the name of the organization and the dates of services.
Referral Source Signature
Clear
Date
Phone number
SUBMIT REFERRAL
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