Send a referral for a mental health patient

Your Source for In-Home Healthcare, Senior Home Care, and Mental Health Care in Houston, Dallas, Fort Worth, Plano, McKinney, Grapevine and the entire DFW Metroplex.

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Send a Referral

We value referrals

To send a referral - print out our Referral Form and fax it to 1-972-233-1099 or just complete the form below

Patient Information

Date:

Last Name:

First Name:

Gender:

Male

Female

Street Address:

City:

State:

Zip Code:

Phone Number:

Alternate Number:

Responsible Party:

Relationship:

Referral Source

Type Of Referral Source:

Self

POA

RN,LMSW

PCP (NAME)

Other (Specify)

Contact Person:

Email:

Phone Number:

Fax Number:

Financial and Insurance Information

Primary Insurance:

Medicare

Medicaid

Private Pay

Private Insurance

Other (Specify)

GroupNumber:

ID or Policy Number:

DOB:

Social Security Number:

Symptoms and Behaviors

	Anxiety, irritability, or restlessness		Argumentative or Uncooperative
	Phobias		Depression
	Schizophrenia		Bi-polar
	Substance Abuse		Emotional Outbursts
	Exacerbation of health problems		Sleep problems or disorders
	Impulsive		Decline in functioning
	Hallucinations		Personality disorder
	Inappropriate sexual behavior		Aggressive or disruptive behavior
	Poor adjustment to a medical condition		Self abuse or multilation
	Social isolation or withdrawal		Danger to self or others
	Suicidal Ideation		Poor appetite or significant weight fluctuation
	Non compliant with medical or nursing care		Other

Chronic Condition:

Oncology

Multiple Sclerosis

Diabetes

Muscular Dystrophy

Other

Additional Information

How long has the patient/client had services with you?:

Do you have any safety concerns for the client?

Is there any potential for violence or harm befalling anyone in the home?

Are there animals that pose a problem for a visitor in the home?

Does the client or someone in the home smoke or abuse alcohol or street drugs?

What are the names and contact numbers of other support services in this home?